ASSESSMENT NSG.

SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

SUBJECTIVE: Pain due to Pigment stones After 8 hours INDEPENDENT After 8 hours
“Masakit ang the gallstones which contain of nursing of nursing
tagiliran ko” and an excess of intervention, 1. Observed and 1. Assist in interventions
microcrystals unconjugated the patient’s documented differentiating ,the patient’s
P:when moving present inside pigments in the pain will be location of pain cause of pain pain was
Q: moderate the gall bile and lessened or severity (0-10 and provides lessened as
pain bladder, the cholesterol relieved as scale), and information evidenced by
R: right upper gallbladder stones which evidenced by character of pain. about disease the pain scale
quadrant can't contract result from bile the pain scale progression from 8/10 to
abdomen properly which supersaturated from 8/10 to development 3/10.
S: 8/10 creates pain with cholesterol 0/10. of
T: pain before in the due to complications
admission in epigastric increased and
hospital area. A cholesterol and effectiveness
gallstone decreased of intervention
OBJECTIVE: produces synthesis of bile
-facial mask of visceral pain acids that 2. Promoted bed 2. Bed rest in
pain. by obstructing dissolves rest and in low low Fowlers
the cystic duct cholesterol fowlers position. position
-guarding or ampulla of which results to reduces intra
behavior Vater, abdominal pain abdominal
resulting in if not removed. pressure.
-jaundice distention of
accompanied the
by marked gallbladder or
itching biliary tree.
-yellowish color Reference: 3. Used soft 3. Reduces
of nails skin Medical- cotton linens, irritation
and sclera of Surgical calamine lotion, oil dryness of the
the eye. Nursing 7th bath and cool as skin and
Edition moist compress as itching
-self focusing indicated. sensation.

-v/s taken as 4. Encouraged 4. Promotes

follows: use of relaxation rest redirects
T: 37.3 technique. attention may
P:80 enhance
R:18 coping.
BP:110/90
COLLABORATIVE

Administered Relieves pain.

medication as
prescribed:
-anticholinergics
-narcotics