Nursing Care Plan

Requirement

Present a 500 words nursing care/action plan based on a scenerio.

Solution

Objective:

  1. •    Rigid abdomen

  2. •    Rated pain as 7/10 within a pain scale of 0-10

  3. •    Wrinkled nose

  4. •    Restless

  5. •    Pacing

  6. •    Rapid breathing

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Nursing Care/ Action

Problem: Abdominal Pain
Nursing Diagnosis: Providing altered comfort which is release the abdominal pain.
Cause Analysis: The acute abdominal disease is found to be associated with indigestion, mostly it is considered as the common symptom of GI dysfunction
Taxonomy: Nutritional Metabolic intake.
Planning: It is planning to get rid of the pain to the patient after 2 hours of nursing interventions. The rate of pain comes down to 2/10 from 7/10.
Intervention:
Independent action:

  1. •    Observing or monitoring the signs as well as symptoms associated with pain, like BP, restlessness, ability to focus, heart rate, moisture of the skin, temperature of the body as well as color of the skin (McQuay, Moore, & Justins, 2016).

  2. •    Assessing the probable cause of pain.

  3. •    Assessing pain characteristics like quality, relieving factors, onset, severity, duration, location and precipitating (Blogger, 2018).

  4. •    Responding immediately for the complaint of the pain.

  5. •    Anticipating the need for the pain relief.

  6. •    Assessing the patient for willingness or the ability for exploring the range of the techniques that is aimed at controlling the pain.

  7. •    Encouraging the patient with frequent and small meals (Black, 2014).

  8. •    Assessing the knowledge of patient which will be preference on the array for the pain relief strategies that available.

  9. •    Identifying the limit of foods which will cause discomfort like, spicy foods or any carbonated drinks (Wayne, 2016).

Dependent action:

  1. •    Administering the analgesic on behalf of pain relief, like morphine sulfate.

  2. •    Administering the antacids, like Magnesium Hydroxide or Aluminum Hydroxide (TazKai LLC NRSNG, 2018). 

Collaborative action:

  1. •    Providing and implementing the prescribed dietary modifications.

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Rationale

  1. •    The data has been used for identifying the extent for the pain along with the baseline information.

  2. •    There may be different etiological factors which are responding better for different therapies.

  3. •    Some patients will unaware for the effectiveness in case of non-pharmacological methods as well as in willing to try them either with or instead of traditional analgesic medications. In very often the combination for the therapies like mild analgesics along with the distraction or the heat may prove with most effective (Morton, Fontaine, Hudak, & Gallo, 2017).

  4. •    The individual can effectively deal with the pain through taking prevention for it. An early stage of intervention will decrease the total amount of analgesic required.

  5. •    There are some patients who feel uncomfortable for the alternative method of pain relief. Those are needed to inform that there are many ways to control the pain (Jerraya,         Gouta, Safta, & Dziri, 2015).

  6. •    Patients can have the experience an exaggeration for pain or in other case there may be decreased of ability for tolerating the painful stimuli for environmental, intrapsychic       as well as intrapersonal factors for further stressing those patients.

  7. •    Small meal can help to prevent the distention as well as gastrin release.

  8. •    The pain will be relieved through neutralizing stomach acid with the increment of bicarbonate as well as secretion (Rees, Parker, Stephens, Telfer, & Wright, 2003).

Evaluation

The goal has met. After 2 hours of nursing intervention, the patient (Lisa) verbalized relief from the acute abdominal pain and the rate comes down to 2/10 from 7-8/10.

Reference

  • Black, J. (2014). Medical Surgical Nursing. Clinical Management for Positive Outcomes, 57-89.

  • Blogger. (2018). Acute Pain related to Abdominal Distention. Retrieved from https://nandanursingdiagnoses.blogspot.in: https://nandanursingdiagnoses.blogspot.in/2014/08/acute-pain-related-to-abdominal.html

  • Jerraya, H., Gouta, E., Safta, A., & Dziri, C. (2015). Jejunal Diverticulitis: A Challenging Diagnosis. Journal of Gastrointestinal & Digestive System, 478-337.

  • McQuay, H., Moore, A., & Justins, D. (2016). Treating acute pain in hospital. BMJ: British Medical Journal,, 1531.

  • Morton, P. G., Fontaine, D., Hudak, C. M., & Gallo, B. M. (2017). Critical care nursing: a holistic approach. Philadelphia, Pennsylvania, United States: Lippincott Williams & Wilkins.

  • Rees, D. C., Parker, N. E., Stephens, A. D., Telfer, P., & Wright, J. (2003). Guidelines for the management of the acute painful crisis in sickle cell disease. . British journal of haematology, 744-752.

  • TazKai LLC NRSNG. (2018). Abdominal Pain. Retrieved from https://www.nrsng.com: https://www.nrsng.com/care-plan/abdominal-pain/

  • Wayne, G. (2016, 08 03). Acute Pain. Retrieved from https://nurseslabs.com: https://nurseslabs.com/acute-pain/

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