ASSESSMENT NURSING NEEDS OBJECTIVE OF NURSING INTERVENTION EVALUATION

DIAGNOSIS CARE

Subjective Data: Acute Pain in the H After 6 hours of 1. Assess the cause, location, After 6 hours of nursing
- Patient Abdomen related to E nursing intervention, and severity of pain intervention, the patient was
verbalized the obstruction of A the client should be R: To obtain baseline data for able to:
6/10 pain gallstones in the bile L able to: planning intervention
scale duct T - Verbalize GOAL MET
- Patient H understanding 2. Monitor Vital Signs and Pain
pointed the of causative Score regularly - Verbalized
pain and M factors R: Monitoring helps to provide understanding of
tenderness in A - The patient prompt and early treatment causative factors. The
the right N pain will be patient verbalized
upper A relieved or 3. Provide comfortable position “Iwasan sajud nako
quadrant of G controlled and by lying on the left lateral position kaon og mga pork
the abdomen E decrease in and pillows supported to the labaw na mga pinirito
M pain score sides kay mao diay
Objective Data: E R: To provide comfort nakapasamot sakit
- Tender & N sakong lawas”
Rigid T 4. Advice the client to take low fat - Pain scale reduces to
abdomen diet like bland diet and to drink 2/10
- Restless and more liquids and eat light diet
agitated R: ETo prevent aggravation of
behavior due pain
to pain
5. Advice the client to avoid
foods like milk, cream, cheese,
fried foods, pastries, and nuts
R: These foods can stimulate the
gallbladder and aggravate the
pain

6. Provide psychological and

emotional support by being with
the client and giving explanations
and cleaning the doubts
R: To provide comfort

7. Provide diversional therapy

and relaxation strategies like
hearing music, reading books,
and watching tv.
R: To divert the mind of the client
from pain

8. Administer drugs like Ursodiol,

chenodiol if prescribed
R: To dissolved the stones and
relieve obstruction of bile duct
thereby relieves pain

9. Assess the need for surgical

management and inform the
client about the various surgical
options available with less pain
and decreased length of stay in
the hospital
R: Client can opt for surgical
treatment with low pain

10. Prepare the client for surgical

procedure and manage
post-operative pain with
analgesics and sedatives like
morphine or codeine as
prescribed.
R: To relieve pain and remove
the gallstones.