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Abdominal Pain – Assessment (Cheat Sheet)
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Example Nursing Diagnosis for Abdominal Pain
- Acute Pain: Abdominal pain can be severe and distressing. This diagnosis addresses the patient's immediate pain management needs.
- Anxiety: Patients with abdominal pain may experience anxiety due to the uncertainty about the cause of pain and potential severity. This diagnosis addresses their emotional well-being.
- Ineffective Coping: Prolonged or severe abdominal pain can lead to difficulty coping with the situation. This diagnosis focuses on assessing and improving coping strategies.
Transcript
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!
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!
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