Nursing Care Plan

Client’s Gender /Age : M/79

Current Diagnosis: Cholelithiasis

Supplementary Data in Addition to Client Initial Assessment Record

Past Medical History: Hyperlipodaemia

Hypertension

Type 2 Diabetes Mellitus

Ex-smoker for 30 years with a 1/2 pack per day, quitted for 10

years

Chronic drinker with a bottle of wine and a nip of whiskey per

night

Chief Complaint(s): Nausea, vomiting and severe right upper quadrant abdominal

pain

Loss of appetite with a 6 kg weight loss in 2 months

Current Treatment(s): Medications:

Amlodipine 10mg daily PO

Metformin 500mg BD PO

Gemfibrozil 300mg BD PO

Tramadol 50mg IMI Q8H PRN

Objective Data: Physical examination:

Jaundice+, complain of skin itchiness over body

Skin warm to touch

Tenderness to deep palpation in the right upper quadrant with

active bowel sounds

Severe right upper abdominal pain with pain score: 7/10 on a 0 -

10 pain intensity rating scale

No change in his bowel habit and no urinary symptoms

Vital Sign:

BP : 140/90 mmHg

Temperature: 38.1⁰C (Hyperthermia)

Pulse : 108 beats/min

SpO2 : 98 (Room air)

Respiratory rate : 18 breaths/min

Laboratory reports:

Abnormal value of white blood cell, bilirubin, ALP, ALT and

AST

White blood cell: 14.2 x 10⁹/L

Total bilirubin: 50umol/L

ALP: 350 IU/L

ALT: 282 IU/L

ASP: 44 IU/L

Diagnostic studies:

Abdominal ultrasonography: Dilatation of the common bile

duct 11 mm and a well-defined oval calculus in the lower
common bile duct. Multiple calculi in a normal gallbladder.
Prioritized Client’s Problems

Problem 1 : Acute Pain

Problem 2 : Imbalanced nutrition

Problem 3 : Deficient knowledge

Problem 4 : Risk for inflammation

Problem 5 ? : Risk for deficient fluid volume

Problem 6 ? :

Problem 7 ? :

Problem 8 ? :

Nursing Diagnosis : Acute pain

Related to : Gallstones in bile duct and gallbladder

As evidenced by : the patient's verbalized 7 out of 10 by pain intensity rating scale

Goal : 1. Patient will rate less than 5 out of 10 for the wound pain

within 5 days.

2. Patient will report progressive pain reduction and pain

relief after interventions, less than 3 out of 10 before

discharge.
Interventions Rationales

1) Continuous assessment for vital signs and 1) Provides a baseline for assessing the

pain by NRS Q4H at 0000-0400-0800-1200- effectiveness of the interventions.

1600-2000

2) Explain the cause of pain and expected 2) Patient who is prepared for pain tend to

duration of pain. relieve stress and consequently less pain.

3) Provide privacy for the client during acute 3) Privacy reduces anxiety and enables more

pain episodes effective coping.

4) Apply non-pharmacological pain-relief 4)

methods daily: a) Distraction stimulates the brain for

a) Distraction endorphins and alters pain

transmission.

b) Breathing exercise b&c) Breathing exercises and relaxation

c) Relaxation techniques techniques decrease oxygen

consumption and muscle tension that

interrupts the cycle of pain–anxiety–

muscle tension.

5) Apply cutaneous stimulation: cold 5) Cold reduces pain by decreasing the

compress. release of pain-inducing chemicals and

slowing the conduction of pain impulses.

6) Reposition the patient in his comfortable 6) Promotes optimal patient comfort and

position. reduces restlessness.

7) Provide optimal pain relief with

prescribed analgesics with:

Outcome evaluation

1. After 5 days, Mr. Chan pain score can reduce from 8 to 5 or less for the wound pain.

2. Pain score reduced to 3 or less before discharge.

Nursing Diagnosis 2 : Imbalanced nutrition

Related to : Loss of appetite due to abdominal discomfort and intolerance of

fatty foods

As evidenced by : Mr Chan lost 6 kg weight in 2 months

Goal : 1.

2.

Interventions Rationales

1) 1)

2) 2)

3) 3)

4) 4)

5) 5)

6) 6)

Outcome evaluation

1.

2.
Nursing Diagnosis 3 : Deficient knowledge

Related to :

As evidenced by :

Goal : 1.

2.

Interventions Rationales

1) 1)

2) 2)

3) 3)

4) 4)

5) 5)

6) 6)

Outcome evaluation

1.

2.
Nursing Diagnosis 4 : Risk for inflammation

Related to :

As evidenced by :

Goal : 1.

2.

Interventions Rationales

1) 1)

2) 2)

3) 3)

4) 4)

5) 5)

6) 6)

Outcome evaluation

1.

2.

Nursing Diagnosis 5 : Risk for deficient fluid volume

Related to :

As evidenced by :

Goal : 1.

2.
Interventions Rationales

1) 1)

2) 2)

3) 3)

4) 4)

5) 5)

6) 6)

Outcome evaluation

1.

2.