nursing care

1. NURSING CARE PLAN
NURSING DIAGNOSIS: ACUTE ADOMINAL PAIN SECONDARY TO INSECTICIDE INTAKE” NON PETROLEUM BASE’”
ASSESMENT PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: “MASAKIT PO ANG
AKIN TYAN” as verbalized by the
patient
(+) guarding behavior
Facial grimace noted
Pain scale 5/10
35 borborygmic sound Left upper
quadrant
BP 160/120
At the end of my ER rotation , the
patient will:
 Report pain is
controlled, reduced
from the pain scale
given by the patient
 Demonstrate pain
easing activities
 Adhere to therapeutic
regimen to the health
care team
Independent:
 Document and assess
Patient pain scale from
time to time
 Coach patient in
diversionary activities in
easing pain, Eg. Deep
breathing exercise
 Position the patient
comfortably
 Give patient
environmental
manipulation eg. Music
therapy, temperature
control,of the room,
 Suggested to Give
Famotidine 20 mg Iv
 Apply soap suds enema
elimination
 Decontaminate perianal
area during bowel
Dependent :
 Refer to Emergency
service for Pain & BP
control Management
 To monitor level of pain
, effectivity of nursing
regimen
 To encourage patient
and participate pain
easing activities (a role
model encouragement
therapy)
 To promote relaxation
and pain reduction
 To promote relaxation
and rest.
 Reduce gastric
irritation/ abdominal
discomfort
 Eliminate /evacuate
insecticide/petroleum
component in G.I tract
 Prevent skin irration and
1st
degree burn
 For pain and BP control
At the end my ER /ward rotation
the patient will exhibit;
 Decrease pain sensation
 Able to control pain via
diversionary activities
 Will have rest and
comfort available to
achieve quality of life
 Continue to do self care
activities
 Reduce borborygmic
activities to normal ( 5-
30/min
 No perianal
complications
 Will have a pain scale of
at least 3/10
 Control BP thru medical
regimen, reduce gastric
irritation