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NCP Ca

- Provide comfort measures - To promote relaxation and comfort. - Encourage fluid intake - To prevent dehydration - Monitor intake and output - To monitor hydration status - Monitor vital signs - To monitor any changes from the previous data. - Monitor pain level - To evaluate effectiveness of interventions. - Report changes in condition - To ensure timely intervention.

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Ann Benito RN
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421 views3 pages

NCP Ca

- Provide comfort measures - To promote relaxation and comfort. - Encourage fluid intake - To prevent dehydration - Monitor intake and output - To monitor hydration status - Monitor vital signs - To monitor any changes from the previous data. - Monitor pain level - To evaluate effectiveness of interventions. - Report changes in condition - To ensure timely intervention.

Uploaded by

Ann Benito RN
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Assessment

Subjective: medyo masakit yung tyan ko the client verbalized. Objective: Abdominal pain Rated pain as 6/10. 1 being the lowest and 10 being the highest.

Nursing Diagnosis
Acute pain related to ductal spasm secondary to biliary duct obstruction

Analysis
Cholangitis is the infection with the bile duct caused by bacteria. It tends to occur if the bile duct is partially obstructed by gallstone. A person with cholangitis may complain with abdominal pain (particularly in right upper quadrant of the abdomen).

Goals and Objectives


Goal After 2 hours of nursing intervention the client will verbalize minimal feeling of pain. Objectves: After 2 hours of nursing intervention the client will

Intervention

Rationale

Evaluation

Independent: - Monitor vital signs - To monitor any changes from the previous data.

Verbalizes methods that provides relief

- Determin e pathophysi ological cause of pain

- To determine precipitatin g factor

- Accept clients description of pain

Pain is a

Demonstrate us of relaxation skills and diversional activities.

subjective experience and cannot be felt by others. - Provide comfort measures such as touch, quiet environme nt and calm activities - Encourag e adequate rest periods

- To promote nonpharma cologic pain manageme nt.

Will follow prescribed pharmacologi cal regimen.

Dependent: - Administ er analgesics - To prevent fatigue

- Collabora te in treatment in underlying condition

- To maintain acceptable level of pain.

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