Cholecystectomy Nursing Care Plan: Post-Operative Acute Pain

Assessment
S: patient
may
verbalize:
> unrelieved
pain
O: patient
may
manifest:
> (+) facial
grimaces
>appears
irritable,
restlessness
>guarded or
protective
behavior
>diaphoresis
>inability to
sleep

Nursing
Diagnosis
Acute pain

Scientific
Explanation
In performing
cholecystecto
my, surgical
incision is
done. By
which, the
incision causes
direct irritation
to the nerve
endings by
chemical
mediators
released at the
site such as
bradykinin.
This irritation
will send signal
to the cortex
and thalamus
of the brain
thus producing
pain
perception.

Planning
(Objective/Goal
)
Short-term:
After 2 hours of
nursing
interventions, the
patient will report
relief from pain.
Long-term:
After 4 hours of
nursing
interventions, the
patient report
pain is controlled.

Interventions
1. administer
medication
as ordered
2. Monitor and
record vital
signs
3. assess the
severity,
frequency,
and
characteristi
c of pain
4. provide
divertional
activities
such as
reading
newspapers

Rationale
1. to
minimize
the pain
2. for
baseline
data
3. pain is a
subjective
data,
therefore it
should be
reported
and to
determine
patients
level of
pain

4. to divert
5. provide nonthe pain
pharmacolog
the patient
ial
is
intervention
experienci
such as
ng
touch and
frequent
changing of
5. to provide

Evaluation
Short-term:
After 2 hours
of nursing
interventions.
the patient
shall have
reported
relief from
pain.
Long-term:
After 4 hours
of nursing
interventions,
the patient
shall have
reported pain
is controlled.

position

comfort