Learning to write a nursing care plan for abdominal pain will ensure quality outcomes. This lesson will look at how a nurse can write a care plan for abdominal pain no matter the underlying diagnosis.
After completing this lesson, nursing students will be able to:
- Write a Nursing Care Plan for abdominal pain
- Describe an assessment of a patient with abdominal pain
- Determine the nursing diagnosis of a patient with abdominal pain
- Create a plan and goals for a patient with abdominal pain
- Write a nursing implementation list for abdominal pain
- Evaluate the effectiveness of a nursing care plan for abdominal pain
- Understand and explain the nursing interventions and rationales associated with an abdominal pain nursing care plan
Pathophysiology of Abdominal Pain
Abdominal pain can be a minor issue that is easy to resolve or a medical emergency. Many different things can cause abdominal pain and their pathophysiology can differ widely. Abdominal pain can is classified as either acute or chronic. When a patient presents to the emergency department or outpatient environment with abdominal pain, it generally constitutes a lengthy workup to determine the cause and its pathophysiology. Additionally, abdominal pain can be referred pain, which can complicate the clinical picture even further.
Etiology of Abdominal Pain
Abdominal pain can be the result of pregnancy, ectopic pregnancy, trauma, a long list of gastric issues (gastroenteritis, constipation, diarrhea, irritable bowel syndrome, GERD, Chron’s disease, appendicitis, to name a few), hernias, allergic response, endometriosis, gallstones, severe menstrual cramps, hepatitis, miscarriage, and many more. Many disease processes result in abdominal pain, and some may present with abdominal pain even though it is not the typical clinical picture.
Cease painful stimuli, resolve the underlying cause, minimize any subsequent damage.
Writing a Nursing Care Plan Abdominal Pain
A Nursing Care Plan (NCP) for abdominal pain starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.
Making an individualized assessment of abdominal pain begins by focusing on the available background information of the patient: health history, current health status, psychological state, and other relevant data.
Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of abdominal pain, a patient might report feeling:
- Abdominal pain
- Decreased appetite
- Rebound tenderness
- Muscle tension
Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of abdominal pain, a patient may present with:
- Electrolyte imbalances
A nursing diagnosis is a basis for establishing and carrying out a nursing care plan. After performing a proper assessment, formulate a nursing diagnosis based on problems associated with abdominal pain. This will be your clinical judgment about the patient’s health conditions or needs.
Select the appropriate nursing diagnostic label from the NANDA-I list of approved nursing diagnostic statements that best identify with the patient’s signs and symptoms. One or more nursing diagnoses may be given.
Planning / Outcomes
Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes.
In the case of abdominal pain, a plan may include:
- Return to normal bowel movements
- Taking medications
- Receiving fluids
- Understanding their condition and treatment
Implementations are actions and activities you will take to achieve the nursing plan goals.
In the case of abdominal pain, an implementation may include:
- Encourage evacuation
- Encourage eating
- Administer medications as prescribed
- Provide fluids
- Educate the patient and family members
The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions.
In our abdominal pain example, an evaluation might include:
- The patient had 2 normal bowel movements
- The patient ate 3 meals
- Patient took medications
- Patient received fluids
- The patient understood information about their care
Nursing Interventions and Rationales
|Assess pain||We must have a detailed baseline to treat appropriately and know if it has changed. For example, a sudden relief of pain in a patient with appendicitis indicates rupture and an emergency.|
|Control pain||Patients who are in pain have trouble participating in care, relaxing, sleeping, and healing. Do what is necessary to proactively treat the patient’s pain and notify the provider of changes or an inability to provide adequate relief. Examples: repositioning, heat/cold, medications (muscle relaxants, analgesics), and other as clinically appropriate|
|Assess bowel movements (color, consistency, frequency, amount)||Assessing bowel movements will aid in making clinical decisions. It is essential to report bowel movement characteristics and frequency accurately. It also ensures accurate intake and output recording.|
|Ensure adequate hydration; may require intravenous fluids||Patients with abdominal pain may have a diminished appetite, be NPO, or not want to drink fluids. Assess and promote appropriate fluid balance, which may require notifying the provider of a decreased oral intake and the need for intravenous fluids to maintain fluid balance.|
|Assess bowel sounds||It is essential to know the patient’s quality as a baseline and routinely reassess to detect changes. If a patient has bowel sounds but now does not, it is essential to detect and notify the provider, as they may not experience any symptoms.|
|Facilitate normal bowel patterns||Abdominal pain can be due to issues with the GI tract. It is essential to proactively address nausea, vomiting, constipation, and diarrhea as clinically appropriate.|
|Record intake and output||Patients with abdominal pain may not be taking in the necessary amount of fluids or foods. Their urinary and/or bowel output may also be lacking. Accurate I&O is essential for appropriate clinical decision-making.|
|Prevent infection||Pathogens (gastroenteritis, for example) can be the cause of abdominal pain. It is essential to promote adequate hand hygiene and infection prevention to prevent spreading it to others or prevent the issue from resolving.|
|Assess abdominal distention, report changes in size and quality as appropriate||Patients may be experiencing abdominal distention as part of the underlying disease process.|
- Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition
- Abdominal Pain in Elderly Persons
- Pathophysiology of abdominal pain
- Abdominal Pain – Vanderbilt Scholl of Medicine
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
Hey guys, let’s look at abdominal pain for a patient and how we’re going to put that into a nursing care plan.
First, we’re going to collect our data. Remember, our data is just our assessment, so subjective from the patient and objective from the nurse. A patient with abdominal pain, that’s having symptoms, the subjective data for this patient is likely going to be the pain, maybe they have a decreased appetite, and how about some nausea? Those kinds of things are going to be all their subjective data.
For objective data, maybe they feel really restless. This is what the nurse is observing. Let’s say we see on this patient, that the patient is having some guarding of the abdomen. Maybe some rebound tenderness when they’re pushed down. Maybe we see, or assess the patient and realize they’re constipated or have constant vomiting or diarrhea. These kinds of things will be our objective data.
My hypothetical patient for our care plan will say that they’re having abdominal pain and it’s from excessive vomiting. We have to analyze the information. This is going to help us to diagnose and prioritize. So what is the problem? Well, the problem is the pain and the problem is that they are having some excessive vomiting. So, what needs to be improved? What can we do to improve or what needs to be improved to help the patient, is going to be the pain, right, but more than that, we need to, for this patient, we need to fix the vomiting, so that can help fix the pain. What is our priority? So, our priority is going to be to stop the vomiting and to help that abdomen just not be so tender right, so stop that vomiting, which is going to help with the pain for this patient and relieve that pain.
So we’re going to ask our “how” questions now, and this is going to help us to plan, implement and evaluate. How did we know it was a problem? Remember, this is where you link your data. So, all your assessment that you have on your patient that you saw in clinical, you’re going to link that data together, and that’s how you knew it was a problem. My hypothetical patient knew what their problem was, because they said that they’d been vomiting for over 24 hours, something like that. So that’s going to be what my problem is, or the patient’s problem, the vomiting that is causing the abdominal pain.
How would I address it? We have to find the cause, right? Just in general, for any abdominal pain patient, you have to find what the cause is, because then you can fix that, and then it will fix the pain. This could vary. We could address it with, if it’s constipation causing abdominal pain, then a laxative, if we have electrolyte balances, we’re going to fix that. We could try positioning, heat, or analgesics. So, for vomiting,we’re going to address it by helping to hopefully stop the vomiting and treat their symptoms, other symptoms that could be making this worse. Then how would I know it gets better? Well, the patient is going to hopefully stop all the excessive vomiting, right? Then the pain will be better, which is what we want.
So, here are high level nursing concepts. For my patient, I’m going to say comfort, right, because they’re having the pain. Elimination because we are vomiting so much and then, patient education, always a good one to have. Alright, so now let’s use whatever sheet you use or whatever form and we’re going to transcribe and put it into a care plan.
So here, our problems and priorities are comfort, elimination, and patient education. We are going to take our assessment data. We’re going to provide an intervention to help fix that data. Then, we’re going to explain why that intervention should work. That’s our rationale, is the why. Then our expected outcome, what do we expect to have happen from this?
So, our comfort. This patient was guarding, they were tender, maybe they were moaning. That’s my data that I collected. I am going to intervene by turning the patient, changing positions, maybe applying heat, if they would like that. My rationale is just that these things can help with the pain and provide comfort. So, my expected outcome would be that the patient will be relieved of the pain or at least that they would be, just more comfortable. So, that’s my expected outcome.
Now let’s look at elimination. My patient has been vomiting for over 24 hours. That’s my data and that’s a problem with elimination, so I need to intervene. Zofran, hopefully we have it ordered, so if ordered, any of this in your care plan, if you’re giving a medication, you would put it as ordered, because you’re not prescribing medications, the doctor is, so we would give Zofran, hopefully I have it ordered, and that will help the patient. Let’s look at the why, or our rationale. So the rationale is that it’s going to stop the vomiting, which is going to help with the pain. And then, our expected outcome is that the elimination will be altered, relieving the pain.
Alright. so our patient education is just some data that we could give to help educate this patient on the abdominal pain, the vomiting, all of that. Perhaps some diet changes for my patient. We would maybe need to educate them on a bland diet, right. Just to help kind of let that gut to rest a little bit if they’re able to eat. Hand hygiene, especially because of all the vomiting, we don’t know what it’s from, if it is viruses and bacteria, but good hand hygiene to help prevent it from spreading. So, for our diet changes, having them drink plenty of water, if they can, and especially Gatorade to help with that electrolyte replacement, and telling them a lot about washing hands just to prevent the spread of infection from whatever’s causing the vomiting.
And also just to add here, because I left it off, is that bland diet just to help their gut heal and rest.
So, the reason why our rationale, like I said, we’re replacing loss fluids. We’re replacing those electrolytes with Gatorade and the bland diet is going to help that gut heal and then infection prevention. So that’s why we’re telling them to wash their hands, right? So, our expected outcomes, anytime you have patient education, the patient is going to be able to verbalize an understanding of the items that you’ve covered. And, that is our outcome. To know that the patient will hopefully be successful.
Alright guys, let’s review our key points here. So, we are going to collect our information and that is always your assessment data. Your subjective and objective facts about the patient. We’re going to analyze that information, so that we can diagnose and prioritize. We are going to ask how, and then it’s going to help us to plan, implement and evaluate. Then we’re going to translate. Translating should be as concise terms. Transcribe whatever form you use for your care plans. Just get it on paper and link all your pieces together.
Alright, that was it for our abdominal pain for nursing care plans, go check out all of our great nursing care plans that we have available for you and how to write a nursing care plan. We love you. Now, go out and be your best selves today and as always, happy nursing!