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Nursing Care Plan Cues Nursing Diagnosis Background Knowledge Goal and Objectives Nursing Interventions and Rationale Evaluation Subjective: Goal Met

The nursing care plan addresses a client experiencing acute abdominal pain related to ulcerative colitis. Nursing interventions include administering morphine sulfate and hydrocortisone IV to manage pain and decrease inflammation, monitoring pain with scheduled acetaminophen and morphine, and providing comfort measures and diversional activities to promote relaxation and coping. The goal is for the client to report reduced pain within 8 hours.

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Zanie Cruz
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170 views4 pages

Nursing Care Plan Cues Nursing Diagnosis Background Knowledge Goal and Objectives Nursing Interventions and Rationale Evaluation Subjective: Goal Met

The nursing care plan addresses a client experiencing acute abdominal pain related to ulcerative colitis. Nursing interventions include administering morphine sulfate and hydrocortisone IV to manage pain and decrease inflammation, monitoring pain with scheduled acetaminophen and morphine, and providing comfort measures and diversional activities to promote relaxation and coping. The goal is for the client to report reduced pain within 8 hours.

Uploaded by

Zanie Cruz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Nursing Care Plan

Cues Nursing Background Goal and Nursing Interventions Evaluation


Diagnosis knowledge Objectives and Rationale

Subjective: Acute pain Ulcerative Colitis is Goal: Aftter the Goal met
related to caused by chronic, nursing
- “my stomach hurts so much
prolonged long-term interventions, the
I can barely take the pain”
diarrhea and inflammation that client will report The client
Objective: skin/tissue leads to open sores relieve of pain report
irritation as known as ulcers in relieved of
- pain of 9/10 evidenced by the innermost pain with a
- Pain in left lower abdominal abdominal pain lining of your pain scale of
quadrant that is sharp, colon, or large 0 out of 10
constant, and aggravated by intestine, and Objectives:
movement rectum.
- BP to 85/47 Abdominal
- HR 130 cramping and mild After 8 hours of
- RR 29 to severe pain in nursing
- tympanic temperature of both the abdomen interventions, the
38.9°C and rectum are client will be able
- O2 sat. 96% common. The pain to:
- Uncomfortable; quietly may be long-
crying and lying on her left lasting, or it may
side with her knees flexed fade when the 1. Verbalize
and arms holding her inflammation of reduced
abdomen recedes. (Whelan, pain with
2019) pain scale
of 0 out of
10 1. Administer 1
mg of
morphine
sulfate IV
push. Reassess
pain after 15
mins. Note: if
pain still
persist
administer
additional 2 mg
of morphine
sulfate and
continue
reassessing
pain.
Rationale: to
treat and
manage severe
pain

2. Administer 400
mg of
hydrocortisone
IV. Rationale:
to decrease
inflammation

3. Monitor pain
and manage
with scheduled
IV infusion of
acetaminophen
(Ofirmev) 1000
mg every 6
hours and 1 mg
morphine
sulfate IV push
for
breakthrough
pain.
Rationale:
to manage
mild-to-
moderate pain
or moderate-to-
severe pain
with an
adjunctive
opioid. It can
also be used to
reduce fever.

Non- pharmacologic:
4. Encourage
patient to
assume
position of
comfort (knees
flexed).
Rationale:
Reduces
abdominal
tension and
promotes sense
of control.

5. Provide
comfort
measures (back
rub, reposition)
and diversional
activities.
Rationale:
Promotes
relaxation,
refocuses
attention, and
may enhance
coping
abilities.

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