Cholelithiasis

Assessment Diagnosis Planning Intervention Rationale Evaluation

Acute pain After 8 hours of Independent: After 8
Subjective: related to nursing hours of
“Masakit ang inflammation interventions •Observe and •Assist in nursing
tagiliran ko” as and distortion , the patient document differentiating intervention
verbalized by of tissues. pain will be location of pain, cause of pain s, the
patient. relieved or severity (0-10 and provides patient pain
controlled. scale), and information was relieved
Objective:
character of pain. about disease or
•Facial mask of progression, controlled
development of
pain. complications
and
•Guarding effectiveness of
intervention.
behavior.
•Promote bed rest, •Bed rest in low
•Self focusing. and in low fowler’s position
fowler’s position. reduces intra
•V/S taken as abdominal
pressure.
follows: •Use soft cotton •Reduces
T: 37.3 linens, calamine irritation,
P: 80 lotion, oil bath dryness of the
R: 18 and cool or moist skin and itching
Bp: 110/90 compress as sensation.
indicated.

•Control •Cool
environmental surroundings
temperature. aid in
minimizing
dermal
discomfort.
•Promotes rest,
•Encourage use of redirects
relaxation attention, may
technique. enhance
coping

Collaborative:

Administer
medication as
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: risk for After 8 hours Independent: After 8 hours
-“Nauuhaw ako deficient fluid of doing -Maintain accurate -Provides of doing
at parang volume necessary record of I&O, noting information about necessary
natutuyot” as related to nursing output less than fluid nursing
vervalized by excessive intervention intake, increased urine status/circulating intervention
the patient. losses the patient specific gravity. Assess volume and the patient
through will skin/mucous replacement Demonstrates
-The patient gastric Demonstrate membranes, peripheral needs. adequate
feels nauseated. suction; adequate pulses, and capillary fluid balance
vomiting, fluid balance refill. as evidenced
Objective: distension, as evidenced by stable vital
gastric by stable -Monitor for signs, moist
Urine output hypermotility vital signs, signs/symptoms of Prolonged mucous
less than 30ml/ and moist increased/continued vomiting, gastric membranes,
hr. medically mucous nausea or vomiting, aspiration, and good skin
restricted membranes, abdominal cramps, restricted oral turgor,
VS: intake. good skin weakness, intake can lead to capillary
T- 36.0 C turgor, twitching, seizures, deficits in sodium, refill,
P- 121 bpm capillary irregular heart rate, potassium, and individually
RR- 26 bpm refill, paresthesia, chloride. appropriate
BP- 90/ 60 individually hypoactive or absent urinary
mmHg appropriate bowel sounds, output, and
urinary depressed absence of
(+) vomiting 3x output, and respirations. -Reduces vomiting.
@ 30ml absence of stimulation of
vomiting. -Eliminate noxious vomiting center.
sights/smells from
environment.
-Decreases
-Perform frequent oral dryness of oral
hygiene with alcohol- mucous
free membranes;
mouthwash; apply reduces
lubricants. risk of oral
bleeding.

-Use small-gauge -Reduces trauma,

needles for injections risk of
and apply firm bleeding/hemato
pressure for longer than ma formation
usual after venipuncture