Nursing Care Plan

Cues Nursing Background Goal and Nursing Interventions Evaluation

Diagnosis knowledge Objectives and Rationale
Subjective: Acute pain Ulcerative Colitis is Goal: Aftter the Goal met
- “my stomach hurts so much related to caused by chronic, nursing
I can barely take the pain” prolonged long-term interventions, the The client
diarrhea and inflammation that client will report report
Objective: skin/tissue leads to open sores relieve of pain relieved of
- pain of 9/10 irritation as known as ulcers in pain with a
- Pain in left lower abdominal evidenced by the innermost pain scale of
quadrant that is sharp, abdominal pain lining of your Objectives: 0 out of 10
constant, and aggravated by colon, or large
movement intestine, and After 8 hours of
- BP to 85/47 rectum.  Abdominal nursing
- HR 130 cramping and mild interventions, the
- RR 29 to severe pain in client will be able
- tympanic temperature of both the abdomen to:
and rectum are
38.9°C
common. The pain 1. Verbalize 1. Administer 1
- O2 sat. 96% may be of reduced mg of
- Uncomfortable; quietly long-lasting, or it pain with morphine
crying and lying on her left may fade when the pain scale sulfate IV
side with her knees flexed inflammation of 0 out of push. Reassess
and arms holding her recedes. (Whelan, 10 pain after 15
abdomen 2019)
mins. Note: if
pain still persist
administer
additional 2 mg
of morphine
sulfate and
continue
reassessing
pain. Rationale:
to treat and
 manage severe
pain

2. Administer 400
mg of
hydrocortisone
IV. Rationale:
to decrease
inflammation

3. Monitor pain
and manage
with scheduled
IV infusion of
acetaminophen
(Ofirmev) 1000
mg every 6
hours and 1 mg
morphine
sulfate IV push
for
breakthrough
pain. Rationale:
to manage
mild-to-modera
te pain or
moderate-to-se
vere pain with
an adjunctive
opioid. It can
also be used to
reduce fever.
Non- pharmacologic:
4. Encourage
patient to
assume
position of
comfort (knees
flexed).
Rationale:
Reduces
abdominal
tension and
promotes sense
of control.

5. Provide
comfort
measures (back
rub, reposition)
and diversional
activities.
Rationale:
Promotes
relaxation,
refocuses
attention, and
may enhance
coping
abilities.