Nursing Care Plan: Acute Pain Following Laparoscopic Cholecystectomy

Mr. R.T. is a 54-year-old male on post-operative day one following an uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis. On assessment he rated his incisional pain 7/10 on the numeric rating scale, guarded the right upper quadrant, and demonstrated shallow splinted respirations at 22 breaths per minute. Vital signs were otherwise stable, and the surgical dressings were dry and intact.

These clustered subjective and objective cues support the priority NANDA-I diagnosis: Acute Pain related to surgical tissue trauma as evidenced by a self-reported pain score of 7/10, guarding behavior, and splinted respirations. Uncontrolled acute pain after abdominal surgery is not merely a comfort issue; it promotes shallow breathing and immobility that raise the risk of atelectasis and venous thromboembolism (Chou et al., 2016).

Outcomes are written to the Nursing Outcomes Classification (NOC) and framed as measurable, time-bound goals:

• The patient will report a pain score of 3/10 or lower within 60 minutes of analgesic administration.
• The patient will demonstrate effective use of the incentive spirometer, achieving at least 1,500 mL, by the end of the shift.
• The patient will ambulate in the hallway with assistance at least twice before discharge.

Interventions follow the Nursing Interventions Classification (NIC) and a multimodal analgesia framework. Multimodal regimens that pair a scheduled non-opioid agent with as-needed opioids reduce total opioid consumption and opioid-related adverse effects after surgery (Chou et al., 2016).

1. Administer scheduled acetaminophen and reassess pain 30–60 minutes after each opioid dose, documenting the response. Rationale: timely reassessment verifies effectiveness and guards against both under-treatment and over-sedation.
2. Coach splinting of the incision with a pillow during coughing and incentive spirometry. Rationale: mechanical support reduces movement-related pain and supports lung expansion.
3. Reposition and encourage early ambulation. Rationale: mobility lowers venous stasis and stimulates return of bowel function.

By end of shift the patient reported 2/10 pain, reached 1,750 mL on the incentive spirometer, and ambulated the length of the hall once with a steady gait. The first outcome was met; the ambulation goal is partially met and carries forward. The care plan is continued with no revision to the priority diagnosis.