ACUTE PANCREATITIS

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Pain related to  The client should  Provide comfort  The client
 Abrupt onset of inflammation of the verbalize and measures (e.g., verbalized and
aching, burning, pancreas and demonstrate relief repositioning), quiet demonstrated relief
stabbing, or accompanying skin and control of pain. environment and and control of pain.
pressing central irritation. calm activities to
epigastric pain  The client should promote non-  The client
that may radiate demonstrate use of pharmacological demonstrated use of
to shoulder, chest methods for pain management. methods for
and back. alleviation/control alleviation/control
 Abdominal of pain.  Provide teachings of pain.
tenderness on the use of
 Pruritus  The client and relaxation  The client and the
associated with his/her family techniques such as family verbalized
jaundice should verbalize focused breathing to understanding about
understanding about distract attention dietary restrictions
dietary restrictions and reduce tension. and modifications.
Objective:
and modifications.
 Elevated
temperature  Encourage
verbalization of
 Jaundice
feelings about pain.
 Board-like
abdominal
tenderness  Administer
prescribed
analgesics to
maintain
“acceptable” level
of pain.
ACUTE PANCREATITIS

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Ineffective breathing  The client should  Encourage  The client verbalized
 Abrupt onset of pattern related to pain verbalize and adequate rest and demonstrated
aching, burning, and pulmonary demonstrate relief periods between relief and control of
stabbing, or infiltrates. and control of pain. activities to limit pain.
pressing central fatigue.
epigastric pain  The client should  The client
that may radiate demonstrate  Use the semi- demonstrated
to shoulder, chest effective breathing fowler’s position effective breathing
and back. pattern. and encourage pattern.
 Abdominal deep breathing and
tenderness coughing to
 Pruritus promote deeper
associated with respirations and
jaundice prevent respiratory
 problem.
Objective:
 Assist client in
 Elevated breathing
temperature retraining (e.g.
 Shallow diaphragmatic,
respirations pursed-lip, etc.), as
 Vomiting indicated.
 Shock,
tachycardia,  Encourage use of
hypotension relaxation
 Board-like techniques, such as
abdomen with focused b reathing,
peritonitis to distract attention
and reduce tension.
ULCERATIVE COLITIS

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Imbalance nutrition; less  The client should  Weigh at regular  The client
 Abdominal pain than body requirements demonstrate intervals and demonstrated
 Weakness related to inability to progressive weight document results to progressive weight
 Anorexia absorb foods due to gain toward goal. monitor gain toward goal.
biologic factors. effectiveness of
 The client should dietary plan.  The client verbalized
verbalize understanding of
Objective: understanding of  Discuss eating habits causative factors and
 Passage of causative factors and including food necessary
necessary preferences, interventions.
bloody mucoid
interventions. intolerances to
loose stools 5x a
appeal to client’s
day
likes/dislikes.
 Hyperactive
bowel sounds
 Evaluate impact of
cultural, ethnic or
religious
desires/influences
that may affect food
choices.
ULCERATIVE COLITIS

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Chronic pain related to  The client should  Assess for  The client verbalized
 Changes in sleep inflammation and verbalize and conditions and demonstrated
patterns ulceration of the bowel demonstrate relief associated with long relief and control of
 Fatigue mucosa and and control of pain. term pain. pain.
 Anorexia accompanying skin
irritation.  The client should  Evaluate current and  The client
verbalize past analgesic/opiod verbalized
Objective:
recognition of drug use. recognition of
 Reduced
interpersonal/family interpersonal/family
interaction with dynamics and  Determine dynamics and
people reactions that affect individual client reactions that affect
 Depression the pain problem. the pain problem.
threshold for pain.
 Weight loss
 Sympathetic  The client should  Note lifestyle effects  The client
mediated demonstrate of pain. demonstrated
responses behavioral behavioral
modifications of modifications of
lifestyle and lifestyle and
appropriate use of appropriate use of
therapeutic therapeutic
interventions. interventions.
CHRON’S DISEASE

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Risk for imbalanced  The client should  Weigh daily, or as  The client
 Nausea fluid volume. demonstrate indicated and demonstrated
 Severe adequate fluid evaluate changes as adequate fluid
abdominal pain balanced as they relate to fluid balanced as
cramping and evidenced by stable status. evidenced by stable
spasms V/S, palpable V/S, palpable
pulses/good quality;  Auscultate BP, pulses/good quality;
Objective: normal skin turgor; calculate pulse normal skin turgor;
 Weight loss moist mucous pressure. moist mucous
 Fever membranes. membranes.
 Passage of  Monitor V/S
watery stools 20x  The client should responses to  The client noted
a day note potential activities. BP and potential sources of
sources of fluid loss heart rate/respiratory fluid loss.
(e.g. presence of rate often increase
conditions such as initially when either  The client
bowel obstruction). fluid deficit is measured/estimated
present. the amount of watery
 The client should stool.
measure the amount
of watery stool;
weigh
diapers/continence
pads, when
indicated.
CHRON’S DISEASE

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Imbalance nutrition; less  The client should  Assess drug  The client
 Lack of interest than body requirements demonstrate interactions, disease demonstrated
in food related to hyper motility progressive weight effects, allergies, use progressive weight
 Perceive inability and malabsorption. gain toward goal. of laxatives, gain toward goal.
to digest food diuretics that may be
 Abdominal  The client should affecting appetite,  The client verbalized
cramping verbalize food intake and understanding of
Objective: understanding of absorption. causative factors and
 Presence of causative factors necessary
blood and fat in when known and  Auscultate bowel interventions.
feces necessary sounds. Note
 Loss of weight interventions. characteristics of  The client
with adequate stool. demonstrated
food intake  The client should behavioral
demonstrate  Evaluate total daily modifications and
behavioral food intake. lifestyle changes to
modifications and regain and maintain
lifestyle changes to appropriate weight.
regain and maintain
appropriate weight.

By: Jayvee C. Candelaria BSN 4-4