Nursing diagnosis:
Acute pain related to obstruction and inflammation as evidenced by self-reports of pain, grimacing, protective behavior.
Goal/ outcome :
1. To reach comfort level
2. To control pain behaviour
3. To reduce the severity of symptoms.
Nursing interventions:
1. Administer analgesics
2. Provide comfort devices to reduce pain and ensure safety.
3. Reduce anxiety of the patient by providing reassurance and assistance.
4. Manipulate the environmental stimuli which may aggravate the symptoms.
5. Administer IV fluids to hydrate the patient as well as to provide bowel rest.
Evaluation
The patient has reached comfort level by implementing pain control behaviours and pain management and the severity of the symptoms reduced.
Or
The patient has not reached the comfort level and the severuse is not reduced and further planning is required.
(Any of the above evaluation can be used depends on patient's condition and progress).
Discharge planning with teaching instructions and plan :
Once the patient achieved the desired outcome , discharge can be planned and at the time of discharge a thorough explanation should be given to the patient and the relatives regarding the do's and dont's and follow up care. It also depends on what treatment they have taken either a medical or a surgical management.
In case of medical management:
Explain regarding drug compliance- explain your patients to take the medicine on time at correct dose. Also explain them not to stop taking medication without the doctor's prescription. Tell your patient about the action of antibiotics and the importance of completing the course.
Advice them to call the health care provider if they feel the medicine is not effective or the pain is increasing.
Explain them to take the medicine list if they have an emergency visit again or for follow up.
Advice them the importance of follow up care .
Teach them the side effects that can happen. And also teach them the healthy foods they should take. Teach them to avoid high fat diet , diary products and gas forming foods.
If the patient have undergone surgical management ie, laparoscopic cholecystectomy then the teaching plan should include :
Explain the possibility of abdominal and shoulder pain so that if the pain occurs, the patient should not get unnecessary anxiety about a heart attack.
Teach the patient to avoid immersing the abdomen in the bathtub for the first 48 hours
Explain them to take the prescribed antibiotics to prevent any infection, and to observe the incisions for signs of infection
Instruct the patient regarding how to care the abdominal wound including changing the dressing and protection of any drains.
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