Professional Documents
Culture Documents
SUBJECTIVE
Verbalized sharp,
burning pain with
an intensity rating
of 5 on the scale of
1-10 at the
epigastric area.
OBJECTIVE
Slight facial
grimacing noted
Minimal
perspiration
Guarding of
abdomen upon
movement
Frequent touching
of epigastric region
Ultrasound Report:
The gallbladder is
normal in size and
configuration. A 0.8
cm intense echo is
noted within the
lumen with
characteristic
shadowing
posteriorly.
Nursing
Diagnosis
Objectives
Altered Comfort:
Acute Pain related
to the presence of
0.8 cm stone in
the gallbladder.
Intervention
1. Perform a complete
comprehensive
assessment of pain
to include location,
characteristics,
onset, duration, and
quality.
2. Encourage the
patient to verbalize
feelings regarding
pain experience.
3. Reduce or eliminate
factors that
precipitate or
increase pain
experience.
4. Manipulate the
environment as
necessary such as
maintaining a clean,
wrinkle-free bed.
5. Offer back rub to
the patient.
6. Encourage the use
of stress
management
techniques, such as
deep breathing
exercises.
Rationale
According to Ida Jean Orlandos
Nursing Process Discipline, nurses
action should be deliberative, rather
than automatic. It should explore the
meaning and relevance of an action.
Evaluation
After our 8 hours
nursing care, the patient
was able to have a
decrease perception of
pain as evidenced by:
GOAL MET
Maintained vital
signs within normal
limits
T= 36 C
P= 72 bpm
R= 18 cpm
BP= 120 mmHg
GOAL MET
Verbalized relief
from discomfort
GOAL MET
Rated pain as 2 on
the scale of 1-10
GOAL MET
Showed absence of
expressive behaviors
such as restlessness
and facial grimacing
GOAL MET
Appeared relax
GOAL PARTIALLY
MET
Identified only 3
strategies to maintain
an acceptable
comfort level