ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
Defining Characteristics
Subjective:
‘’ I am having a sudden
onset of abdominal pain’’
as verbalized by the patient.
Objective:
 Persisted pain that
radiates at her back
 Vomiting
 Distress
 Anxious
 Cyanotic
 Pain scale ( 9/10)
 V/S taken as follows:
 BP= 130/80
 HR= 115 bpm
 RR= 23/ min
 Temp = 38.6 Celsius
( fever)
 Physical Exam
( Abdomen)= Tender in
the epigastruim with
rebound tenderness,
reduced bowel sound
 Lab Results
 Wbc – 13.0 x/ ul ( inc.)
 Platelets – 235/ul( dec.)
 Albumin 1.5 g/dl (dec.)
 Protein -3.15 g/dl (dec.)
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
Nursing Diagnosis Outcome Identification Nursing Interventions Rationale Evaluation
Acute pain and Long Term: Independent: The goal is met after 5
discomfort related to  After 5 days of nursing  Establish rapport.  To gain patient trust and days of nursing
inflammatory process intervention, patient will cooperation with the intervention the patient
of the pancreas no longer manifest patient and family. will verbalized relieved of
possible evidence by abdominal pain;  Monitor and record VS.  To have a baseline data for pain and comfort;
persisted pain that demonstrate use of planning and intervention. demonstrate used of
radiates at the back; relaxation techniques;  Assess level of pain, noting  To identify level of pain. methods that provide
tender in the follow prescribed specific location and intensity. relief.
epigastruim with pharmacological  Promote position of comfort  To promote
rebound tenderness measures. nonpharmacological pain
regimen.
and a pain scale of management.
9/10.  Encourage adequate rest
periods.  To prevent fatigue.
Short Term:
 After 8 hours of nursing
 Maintain fluid and electrolyte  To assess fluid and
Rationale: intervention, the patient
balance. electrolyte status ( e.g.
Acute pain is caused will report pain relieved/
skin turgor, mucous
by edematous controlled; decrease
pain using a scale of
membranes, intake and
distention of the output ). .
3/10.
pancreatic capsule,
local peritonitis
 Maintain bed rest during acute  Decreases metabolic rate
resulting from
attack. Provide quiet, restful and GI stimulation and
enzyme release into
environment. secretions, thereby
the peritoneum,
reducing pancreatic
ductal spasm,or
activity.
pancreatic auto
digestion stimulated
 Provide alternative comfort  To promotes relaxation
by increased enzyme
measures (back rub), encourage and enables patient to
secretion when
eating.
relaxation techniques. refocus attention; may
enhance coping.
Note: Nursing
Diagnosis Should be
base from (NANDA)
Nursing Diagnosis
  LDH – 486.7 u/l (inc.)  Promote position of comfort on  Reduces abdominal
 Glucose – 123 mg/dl one side with knees flexed, pressure and tension,
(inc.) sitting up and leaning forward. providing some measure of
 Neutrophils- 25% (dec.) ( semi- fowler’s position). comfort and pain relief.
 Lymphocytes – 45 %
(inc.)
 ALT – 48 IU/L (inc.)
 AST- 93 IU/L ( inc.)
 Serum lipase – 369
IU/L (inc.) Dependent:  Tramadol is an effective
 Serum creatinine – 5.1  Administer prescribed agent in the management
mg/dL ( inc.) medications, which may include of pain in acute
 CT Scan - showed fat analgesics like Tramadol 100 pancreatitis. Tramadol is
stranding in the mg Q6H as PRN. used to relieve moderate to
pancreatic head moderately severe pain.
consisted of pancreatitis
and reactive thickening  Patient should be kept
in the duodenum.  Withhold food and fluid as NPO status until pain and
 Ultrasound – gross indicated. nausea subside to limit or
ascites with echogenic reduce release of
fluid, increased pancreatic enzymes and
echotexture of liver, resultant pain.
obscured pancreas,
Grade 1 renal
parenchymal disease.
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
Defining Characteristics Nursing Diagnosis Outcome Identification Nursing Interventions Rationale Evaluation
Long Term: Independent: The goal is met after
Subjective: Imbalanced nutrition After 5days of nursing  Establish rapport.  To gain patient trust and nursing intervention
‘’I am having an less than body intervention, the patient cooperation with the patient and the patient have
abdominal pain and I have requirement maybe will demonstrate behaviors, family. displayed
no appetite’’ as verbalized related to loss of lifestyle change to regain  Assess level of pain, noting  To identify level of pain. normalization of
by the patient. digestive enzymes and maintain an specific location and intensity. laboratory values and
and insulin (related to appropriate weight. have demonstrated
pancreatic outflow  Weight the pt. daily and  A record of the pt. weight will behaviors, lifestyle
obstruction or document readings. help assess the progress of changes to regain and
necrosis/ auto treatment. maintain an
Objective: digestion) possible  Maintain fluid and electrolyte appropriate weight.
 Persisted pain that evidence by balance.  To assess fluid and electrolyte
radiates at her back vomiting. status ( e.g. skin turgor, mucous
 Vomiting  Assess abdomen, noting membranes, intake and output ).
 Distress Rationale: presence and character of  Gastric distention and intestinal
 Anxious Nutritional imbalance Short Term: bowel sounds, abdominal atony are frequently present,
 Cyanotic occurs when there is After 8 hour of nursing distention and reports of resulting in reduced and absent
 Pain scale ( 9/10) an abnormal level in intervention, the patient nausea. bowel sounds. 
certain nutrients will display normalization 
 V/S taken as Review laboratory values that
caused by shortage or of laboratory values. indicate well- being or  Laboratory test play a significant
follows:
excess in supply. deterioration. part in determining the patient
 BP= 130/80
 HR= 115 bpm nutritional status. An abnormal
 RR= 23/ min  Provide frequent oral care. value in a single diagnostic
Note: Nursing study may have may possible
 Temp = 38.6 Celsius
Diagnosis Should be causes.
( fever)
base from (NANDA)
 Wt. 80kilos  To decrease vomiting stimulus
Nursing Diagnosis
 Physical Exam  Maintain NPO status and and inflammation and irritation
( Abdomen)= Tender gastric suctioning in acute of dry mucous membranes
in the epigastruim with phase. associated with dehydration.
rebound tenderness,  Resume oral intake with clear  To prevents stimulation and
reduced bowel sound liquids and advance diet release of pancreatic enzymes
 Lab Results slowly to provide high-protein, (secretin).
 Wbc – 13.0 x/ ul high-carbohydrate diet, when
 ( inc.) indicated.  Oral feedings given too early in
 Platelets – the course of illness may
235/ul( dec.) exacerbate symptoms. Loss of
 Albumin 1.5 g/dl Dependent: pancreatic function and reduced
(dec.)  Administer prescribed insulin production may require
 Protein -3.15 g/dl medications such as antiemetics initiation of a diabetic diet.
(dec.) drugs ( Metoclopramide 10mg
 LDH – 486.7 u/l (inc.) IV Q8hr.)
 Glucose – 123 mg/dl
(inc.)  Provide insulin as appropriate.  To decrease nausea and
 Neutrophils- 25% vomiting.Decreased symptoms
(dec.) of gastric stasis.
 Lymphocytes – 45 %
(inc.)
 ALT – 48 IU/L (inc.)  To corrects persistent
 AST- 93 IU/L ( inc.) hyperglycemia caused by injury
 Serum lipase – 369 to cells and increased release of
IU/L (inc.)  Refer dietician for nutritional glucocorticoids. Insulin therapy
 Serum creatinine – 5.1 support. is usually short-term unless
mg/dL ( inc.) permanent damage to pancreas
 CT Scan - showed fat occurs.
stranding in the  Dietitians can help in the
pancreatic head assessment of the patient’s
consisted of nutritional status and nutritional
pancreatitis and needs.
reactive thickening in
the duodenum.
 Ultrasound – gross
ascites with echogenic
fluid, increased echo
texture of liver,
obscured pancreas,
Grade 1 renal
parenchymal disease.