Nursing Diagnosis: Acute pain associated with biological agents injured ductal obstruction or spasm, inflammation, ischemia and necrosis.
It is obvious from
Reports of pain, biliary colic
Facial mask of pain, to monitor the behavior
Autonomic responses, including changes in blood pressure (BP), pulse
Desired outcomes / evaluation criteria, the client
Report pain or controlled release.
Demonstration of the use of relaxation skills and diversional activities under this special situation.
Nursing interventions on the ground:
1. Monitoring and documenting the location, severity (00-10 scale) and the nature of pain as a stable, intermittent or colic.
Background: To support the cause of the pain of discrimination and provides information on disease progression or decisions, the development of complications and efficiency measures.
2. Note: responses to drugs and reports a doctor if the pain disappear.
Background: Severe pain not relieved by conventional methods may indicate the development of complications and the need for further intervention.
3. Encouraging bed rest, and instead of taking the customer's convenience.
Reason: bed rest in the down position reduces intra-abdominal pressure Fowler, but customers will naturally take the least painful position.
4. Use a soft cotton cloth, milk, soot, oil bath, and cool, wet compresses, as directed.
Background: Reduces irritation and dryness and itching.
5. Temperature setting.
Justification: Cool environmental support skin discomfort.
6. Promoting the use of relaxation techniques like guided imagery, visualization and deep breathing exercises. Posted diversional activities.
Background: peace, reorientation, and improved performance incentives.
7. Take time to listen and keep in constant contact with customers.
Background: to help relieve the anxiety and focus on the pain.
8. To maintain nothing by mouth (NGO) status and maintaining a nasogastric (NG) suction, as indicated.
Background: Removes gastric secretion, the release of cholecystokinin and gallbladder contraction stimulates.
9. to prepare for procedures such as sphincterotomy plus the removal of stones during ERCP
Background: Procedures, signed at the mouth of the bile duct that empty into the duodenum worse. This process can be done to get the stones from the joint through a small tube or balloon basket at the end of the endoscope. Stones must be less than 15 mm. Larger stones were crushed with a mechanical lithotripter place through the endoscope.
10. External shock wave lithotripsy ESWL)
Background: Treatment of shock wave therapy is used less for the high recurrence of stones. This may be reflected in the client with mild to moderate symptoms, a stroke of cholesterol (0.5 mm) or client without biliary obstruction. Note: This procedure is contraindicated for clients with pacemakers or implantable defibrillators