GROUP 3; BSN III - 1

Angeles, Mikaella Haveria, Angelique

Ampado, Alessandra Lopez, Kirsten Rebecca
Benitez, Bryanne Loterte, Gillian
Cortez, Kelly Sarausa, Angelo
Domingo, Bea Sustituedo, Nikka

CASE DESCRIPTION

Chief Complaint: Abdominal pain

History of Present Illness

Client reported a sudden and sharp pain in the right lower quadrant and progressively spreads to the mid-abdomen, which started a few days ago. The pain was significantly reduced
thereafter but worsened on the morning of presentation to the emergency room, especially when moving. The pain is not associated with any other symptoms.

He has no significant past medical history and inherited medical conditions but does heavy lifting at work, smokes half a pack of cigarettes per day, and drinks socially.
PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS
 NURSING DIAGNOSIS

Acute Pain related to bowel inflammation as evidenced by reported sudden, sharp pain and abdominal guarding while ambulating
Impaired Physical Mobility r/t pain when moving AEB holding of the abdomen while ambulating
Activity intolerance r/t pain AEB abdominal guarding while ambulating and verbalization of worsening pain upon movement.
Impaired comfort r/t diverticula inflammation AEB reported sudden, sharp pain and verbalization of worsening pain upon movement.
Deficient Knowledge r/t insufficient knowledge about disease process AEB verbalizing inaccurate information about condition

NURSING INTERVENTIONS

Independent Dependent Collaborative EBP

Acute Pain Cognitive-Behavioral Therapy for Pain

1.) Assess the characteristics of pain.
a.) Onset
b.) Location
c.) Duration
d.) Characteristics
e.) Aggravating factors
f.) Alleviating factors
2.) Monitor for changes in bowel habits
3.) Monitor vital signs.
4.) Elevate the head of the bed and place the
patient in Semi-Fowler’s position
1.) Administer analgesics as ordered by the 1.) Refer client to pain specialist as required Management
physician.
2.) Refer to a dietician for nutritional This therapy is used to allow the patient to cope
2.) Provide broad-spectrum antibiotics as adjustments up with the pain she/he experienced wherein it
ordered by the physician. 3.) Refer to other disciplines as indicated changes how you think and perceive the pain. It
a. Physical therapists also helps you to stop thinking about negative
3.) Splinting technique as ordered to b. Occupational therapists thoughts so the body and mind will respond better
minimize the abdominal pain while 4.) Collaborate with other medical to the pain.
moving. professionals for activities such as:
a. Therapeutic touch Kaiser Permanente. (2019, November 19).
4.) Place the patient in NPO as ordered. b. Massage Cognitive-Behavioral Therapy for Pain
c. Healing touch, and Management.
5.) Prepare the client for possible surgery as d. Self-hypnosis. https://wa.kaiserpermanente.org/kbase/topic.jhtml
indicated and ordered. ?docId=tv3092

5.) Place the patient on bed rest during severe 6.) Administer IV fluids as ordered.
episodes of pain

6.) Provide non-pharmacological pain

management techniques
a.) Frequent changes in position
b.) Meditation
c.) Warm compress

7.) Monitor sudden changes in the nature of

 pain.

8.) Place the client in his/her preferred

position to ease the pain.

9.) Teach client on distraction techniques.

Use it to decrease one’s awareness of the
painful experience.

10.) Allow the patient to express his/her

feelings and say what he/she needs.

11.) Raise side rails for safety purposes.

12.) Provide a safe, clean, & comfortable

environment appropriate for balance of
vital functions.

13.) Educate the patient about diagnostics and

procedures.

Impaired Physical Mobility

1. Provide a safe environment by raising the
side rails and put the bed on a down
position

2. Assess for the skin integrity

3. Use devices to and measures to prevent

skin breakdown
a. Foam wedge
b. Air mattresses
c. Heel-offloading devices

4. Reposition the client at least every 2 hours

5. Encourage the patient to do passive or

 active ROM exercise

6. Monitor vitals signs while doing exercises

7. Provide resting periods to promote

restoring of energy.

8. Promote adequate rest by minimizing

environmental stresses and maintaining
quiet room.

Activity Intolerance
1. Assess the client's actual and perceived
limitations in light of abdominal pain.

2. Monitor changes in blood pressure, heart

rate, respiratory rate, and skin color

3. Encourage the client to verbalize

weakness, fatigue, or pain.

4. Ascertain the client’s ability to stand and

move as well as degree of assistance
needed.

5. Determine the client’s current activity

level and physical condition

Impaired Comfort:
1. Establish Rapport.

2. Determine type of discomfort the client is

experiencing

3. Assess the comfort level regularly

4. Assist the patient to find a comfortable

position
 5. Provide relaxation technique preferred by
the client
a. Music therapy
b. Watching televisions/Movies
c. Deep breathing techniques
d. Meditation

6. Change the environment according to the

client’s preference.
a. Temperature of the room
b. Closing curtains
c. Adjusting lighting
d. Reducing noise

7. Allow the client to express his/her

thoughts and feelings

8. Encourage the client to learn or discover

new coping skills.

Deficient knowledge

1. Assess the client’s knowledge about the

diagnosis

2. Determine the patient’s method of

accessing information

3. Assess for the willingness to learn

4. Establish a trusting environment

5. Provide a trusting and conducive

environment to learning

6. Allow the client to express his/her thought

and feelings about the diagnosis
 7. Identify outcomes to be achieved

8. Provide a clear, concise and easy to

understand explanation regarding the
diagnosis

9. Start from the information the client

already knows and proceed to the
unfamiliar, progressing from simple to
complex

10. Encourage patient to ask for question for

clarifications

11. Assess for the client’s progress from time

to time

12. Assist the patient to use information in all

applicable areas

DISCHARGE TEACHINGS

Health
Medication Out-Patient
Teaching/Home Diet Instructions
Education Follow Up
Instructions

Analgesics : ● Post Operative Management home 1. Follow the provider’s instructions for 1. Recommend an increase in fluid intake of
1. Perform Non-pharmacological pain instructions follow-up appointments and educate about 2L/day
management methods/ Management of ○ To care for surgical wounds, keep the importance of attending follow up 2. Maintain a soft diet with increased fiber
side effects the site clean, do hand hygiene check up. content such as:
● Guided Imagery before changing the dressing and 2. Keep appointments for any routine testing a. Prepared cereals
● Distraction after disposing of the dressing. needed. b. Soft-cooked vegetables
● Comfort therapy ( companion, ○ Tell the patient that swelling in 3. Instruct the patient to call healthcare 3. Avoid consuming food triggers that may
exercise, heat/cold application, the surgical incision site is normal provider when: bring upon a diverticulitis attack (ex. nuts
meditation, music/ art and for up to 3 weeks. ● Severe Belly pain that goes away or popcorn)
positioning). ○ Avoid lifting heavy objects then come back worse than it was 4. Create a schedule for meals
 ● Physical therapy (tone and
strengthening, desensitization)
● Psychosocial therapy counseling (
individual/family/group
counseling)
2. Take with meals or milk/ Take with or
without food
3. Avoid alcohol
4. Report symptoms of gastric distress
5. Do not exceed 4 grams / 24 hours
6. Report nausea, vomiting, abdominal pain
7. Take exactly as prescribed
8. Sedation: caution with activities that
require alertness; avoid alcohol
9. Hypotension: sit or lie down if dizzy;
make position changes slowly
10. Constipation: increase fluid and fiber
intake
11. Urinary retention: empty bladder every
four hours
12. Turn, cough, deep breathe regularly.
○ Follow diet instructions as ● Blood in bowel stools (black tarry
prescribed by the dietician stools)
○ Instruct patient to chew or ● Signs of infection:
masticate the food well when - Surgical wound is more
eating red, painful, warm to
○ Sleep 7-9 hrs a day to promote touch, with pus
rest - Fever, chills, muscle
○ Instruct the patient to do light aches
exercises as tolerated to prevent
constipation and promote bowel ● Nausea/ vomiting
movements
● Activity Restrictions
○ Do not drive, and operate
machinery while taking pain
medications as prescribed
○ lessen / restrict alcohol
consumption
○ Avoid smoking (offer different
ways to manage withdrawal
symptoms and diversional
activities)
○

Broad Spectrum Antibiotics :

1. Reminder of Purpose of medication: only

to treat infection
2. Dose: one tablet taken with or without
food
3. Abstain from sexual activity for seven
days, starting after the completion of
therapy
4. Side effects to report:
● Allergies/ rashes
● Signs of infection/ redness on
areas of the body
● Presence of pain in liver or
abdominal area
 ● Difficulty in Hearing
● Inabiliy to balance body weight
● Irregular Heart Beat/ rate

REFERENCES
Cheever, K. H., & Hinkle, J. L. (2018). Brunner & Suddarth's Textbook of Medical-surgical Nursing. Wolters Kluwer.
C. Rn, A. B. (2021, December 29). Alteration in Comfort Nursing Diagnosis and Care Plans. NurseStudy.Net.
https://nursestudy.net/alteration-in-comfort-nursing-diagnosis/
Doenges, M. E., & Moorhouse, M. F. (2019). Nurse's pocket guide: Diagnoses, interventions, and rationales (15thed.). Philadelphia: F.A. Davis.
Kaiser Permanente. (2019, November 19). Cognitive-Behavioral Therapy for Pain Management. https://wa.kaiserpermanente.org/kbase/topic.jhtml?docId=tv3092
McKenry, L. M., & Salerno, E. (2003). Mosby's pharmacology in nursing. St. Louis, Mo: Mosby.