ASSESSMENT SUBJECTIVE: Masakit ang sikmura ko as verbalized by the patient.

OBJECTIVE; -conscious -weak - (+) facial grimace -(+) guarding behavior -Vital Signs: BP: T: P: R: -Pain Scale of -Diagnosis of Doctor: Cholelithiasis

DIAGNOSIS Acute/Severe pain related to biliary spasms as manifested by reports of pain, guarding behavior and pain scale of

PLANNING After 30 minutes to 1 hour of my nursing interventions, the pain perception will be lessened from pain scale of to

INTERVENTION INDEPENDENT: -assess pain status (location, severity, and characteristics of pain).

RATIONALE

EVALUATION

-promote bed rest. -make time to listen and maintain frequent contact with patient. -monitor vital signs. Provided Health Teachings as follows: -reduce fat intake.

-assist in differentiating cause of pain and provides information about disease progression, development of complications and effectiveness of interventions. -Semi-Fowler s position to reduce intra-abdominal pressure. -helpful in alleviating anxiety and refocusing attention which can relieve pain. -to have a baseline data.

GOALS MET (after one hour of my nursing interventions, the patient s pain perception was lessened as evidenced by pain scale of to )

-withhold oral foods and fluids during episodes of acute pain

-fat entering the duodenum initiates gallbladder contractions, causing pain when gallstones are present in the ducts. -emptying the stomach reduces the amount of chime entering the duodenum and the stimulus for gallbladder contractions, thus reducing pain. -removes gastric secretions that stimulate release of cholecystokinin and gallbladder contractions.

DEPENDENT: -maintain on NPO status

-administer medications as ordered: y Tramadol

Diclofenac Na 75mg IM q12 x 2 doses

-centally acting analgesis not chemically related to opioids but binds to mu-opioids receptors and inhibits reuptake of norepinephrine and serotonin. -inhibit cyclooxygenase (cox), an enzyme needed for the

Mefenamic Acid 500mg 1cap q8 PRN for pain

biosynthesis of prostaglandin, subsequent decrease in prostaglandin result to analgesic, antipyretic and anti-inflammatory effects. -aspirin-like drug that has analgesic, antipyretic and antiinflammatory effects. These activity appear due to its ability to inhibit COX and also antagonize certain effects of prostaglandin. Mefenamic acid displays central and peripheral activity.