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  • NCP Sas 10

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    Shyn Margareth
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    1. The patient is experiencing pain in the right upper quadrant of the abdomen consistent with a diagnosis of acute cholecystitis, an inflammation of the gallbladder. 2. The nursing goals are to relieve the patient's pain within 8 hours by promoting rest and administering pain medication as needed, and help the patient learn to manage their pain to prevent recurrence within 3 days. 3. The planned nursing interventions include monitoring the patient's pain level, maintaining bed rest and NPO status, providing comfort measures like cool compresses, administering medication as ordered, and preparing the patient for potential diagnostic tests or procedures.

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    MED SURG 2 SAS 10 NCP

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    NCP SAS 10

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    1. The patient is experiencing pain in the right upper quadrant of the abdomen consistent with a diagnosis of acute cholecystitis, an inflammation of the gallbladder. 2. The nursing goals are to relieve the patient's pain within 8 hours by promoting rest and administering pain medication as needed, and help the patient learn to manage their pain to prevent recurrence within 3 days. 3. The planned nursing interventions include monitoring the patient's pain level, maintaining bed rest and NPO status, providing comfort measures like cool compresses, administering medication as ordered, and preparing the patient for potential diagnostic tests or procedures.

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    22 views2 pages

    NCP Sas 10

    Uploaded by

    Shyn Margareth
    1. The patient is experiencing pain in the right upper quadrant of the abdomen consistent with a diagnosis of acute cholecystitis, an inflammation of the gallbladder. 2. The nursing goals are to relieve the patient's pain within 8 hours by promoting rest and administering pain medication as needed, and help the patient learn to manage their pain to prevent recurrence within 3 days. 3. The planned nursing interventions include monitoring the patient's pain level, maintaining bed rest and NPO status, providing comfort measures like cool compresses, administering medication as ordered, and preparing the patient for potential diagnostic tests or procedures.

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    of 2

    WABINGA, SHYN MARGARETH B.

    SAS 10: CHOLECYSTITIS


    BSN 3- C7

    DEFINING NURSING SCIENTIFIC


    GOAL OF CARE INTERVENTION RATIONALE EVALUATION
    CHARACTERISTICS DIAGNOSIS ANALYSIS
    Subjective Data: Acute Pain Cholecystitis is Short Term: Independent: Independent:
    Patient Verbalizes, “I related to the After 8 hours of 1. Observe and document 1. Assists in differentiating cause of Short Term:
    have fullness and pain in inflammatory inflammation of initiating location, severity (0–10 scale), pain, and provides information The objective is met if
    the right upper process and the gallbladder nursing and character of pain (steady, about disease progression and the patient’s pain has
    quadrant of my tissue which can be intervention, intermittent, colicky). resolution, development of been relieved or
    abdomen.” ischemia as acute or chronic the patient’s 2. Promote bedrest, allowing complications, and effectiveness of controlled as patient
    evidenced by and it causes pain will be patient to assume position of interventions. demonstrates use of
    Objective Data: patient’s pain, relieved or comfort. 2. Bedrest in low-Fowler’s position relaxation skills and
     Facial mask of verbal tenderness, and controlled. 3. Make time to listen to and reduces intra-abdominal pressure; technique as
    pain reports, rigidity of the maintain frequent contact with however, patient will naturally indicated for
     Muscle guarding facial upper right Long Term: patient. assume least painful position. indicated for
    or rigidity when grimace, and abdomen that Within three Dependent: 3. Helpful in alleviating anxiety and individual situation.
    the right upper guarding may radiate to days of initiating 1. Maintain NPO status, insert refocusing attention, which can
    abdomen is behavior. the midsternal nursing and/or maintain NG suction as relieve pain. Long Term:
    palpated area or right interventions, indicated. Dependent: The objective is met if
     Autonomic shoulder and is patient will be 2. Use soft or cotton linens; 1. Removes gastric secretions that the patient’s disease
    Responses associated with able to calamine lotion, oil bath; cool stimulate release of cholecystokinin has been cured as
     Self-focusing nausea, demonstrate or moist compresses as and gallbladder contractions. manifested by
     Narrow focus vomiting, and behaviors that indicated. 2. Reduces irritation and dryness of patient’s pain
    usual signs of can manage the 3. Use soft or cotton linens; the skin and itching sensation. relieved, homeostasis
    acute pain and to note calamine lotion, oil bath; cool 3. Reduces irritation and dryness of achieved and
    inflammation. If possible or moist compresses as the skin and itching sensation. complications are
    a gallstone recurrence of indicated. Collaborative: prevented/minimized.
    obstructs the pain. Collaborative: 1. Severe pain not relieved by routine
    cystic duct, the 1. Note response to medication, measures may indicate developing
    gallbladder and report to physician if pain complications or need for further
    becomes is not being relieved. intervention.
    distended, 2. Encourage use of relaxation 2. Promotes rest, redirects attention,
    inflamed, and techniques. Provide diversional may enhance coping.
    eventually activities. 3. This is to condition the patient’s
    infected.
    WABINGA, SHYN MARGARETH B. SAS 10: CHOLECYSTITIS
    BSN 3- C7

    (Brunicardi, 3. Prepare the patient for body to undergo procedure.


    2019; Cameron procedures such as abdominal
    and Cameron, ultrasound, blood test.
    2020.)

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