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Post Operative Acute Pain

This nursing care plan addresses preoperative acute pain in a patient undergoing cholecystectomy (gallbladder removal surgery). The plan identifies signs and symptoms of acute pain including reports of unrelieved pain and physical manifestations like grimacing or restlessness. The cause of pain is explained as obstruction of bile flow from gallstones, causing gallbladder spasms and inability to release bile. Short term goals are to relieve pain within 1-2 hours through interventions like medication administration and touch therapy. Long term goals are pain control within 4 hours with continued nursing care.

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الأغا محمد زكارنة
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540 views1 page

Post Operative Acute Pain

This nursing care plan addresses preoperative acute pain in a patient undergoing cholecystectomy (gallbladder removal surgery). The plan identifies signs and symptoms of acute pain including reports of unrelieved pain and physical manifestations like grimacing or restlessness. The cause of pain is explained as obstruction of bile flow from gallstones, causing gallbladder spasms and inability to release bile. Short term goals are to relieve pain within 1-2 hours through interventions like medication administration and touch therapy. Long term goals are pain control within 4 hours with continued nursing care.

Uploaded by

الأغا محمد زكارنة
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Cholecystectomy Nursing Care Plan: Preoperative Problem: Acute Pain

Assessment
S: patient may
verbalize:
> unrelieved pain
O: patient may
manifest:
> (+) facial
grimaces
>appears irritable,
restlessness
>guarded or
protective
behavior
>diaphoresis
>inability to sleep
> pain on the
abdominal area

Nursing Diagnosis
Acute pain

Scientific
Explanation
The flow of bile in
the gall bladder is
obstructed due to
the presence of
stones. When the
bladder releases
bile, it contracts
and there is
spasm, thus it
cannot
adequately
release bile due
to the stone, it
stimulates the
release of
cytokines
resulting to pain.

Planning
(Objective/Goal)
Short-term:

Interventions

1. Establish
rapport
After 1-2 hours of
2. Monitor and
nursing interventions,
record vital
the patient will
signs
demonstrate behaviors 3. assess the
to relieve pain
severity,
frequency, and
characteristic
Long-term:
of pain
4. administer
After 4 hours of
medication as
nursing interventions,
ordered
the patient will report 5. provide nonpain is controlled.
pharmacologic
al intervention
such as touch
and frequent
changing of
position

Rationale
1. To gain
patients trust
and
cooperation
2. for baseline
data
3. pain is a
subjective
data,
therefore it
should be
reported and
to determine
patients level
of pain
4. to minimize/
relieve pain
5. to provide
comfort

Evaluation
Short-term:
After 1-2 hours of
nursing
interventions, the
patient shall have
demonstrated
behaviors to
relieve pain
Long-term:
After 4 hours of
nursing
interventions, the
patient shall have
reported pain is
controlled.

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