Nursing Care

A.) NURSING CARE PLAN

Name: SPJ

Age/Sex: 47 years old/ Male

Rm/Bed#: 306-2

Chief Complaint: Abdominal Pain;

Diagnosis: Cholelithiasis

Attending Physician: Dr. Gallardo

Post Open Cholecystectomy

Date

Cues

and

Nee

Diagnosis

Objective of Care

Evaluation

Time
June

SUBJECTIVE:

25,

Mga 4 out of

Acute pain interventions

5 sa pain scale

related

ninyo gang.

subcostal

from

10

As verbalized

suture

evidenced by:

am

by the patient.

secondary

to

open

cholecyste

2015

Interventions

OBJECTIVE:

Abdomi
nal

After 1 hour of nursing 1.) Assess for the site which June 25, 2015
patient pain is felt.

@ 11am

to will experience relief R: Unrelieved pain can create

pain

as more
anxiety,

problems
anger,

such
and

as Goal Met
other

respiratory that may cause After

post A.) Pain Scale of 0 2 the delay of wound healing.

out of 5.
B.)Absence
abdominal guarding.

hour

nursing

Encourage

and

assist patient

of client to do deep breathing experienced relief

guardin

with

g
7am

Intraoperat

R: Deep breathing exercises evidence by:

ive

can enhance relaxation to the

VS:

Cholangio

C.)

Absence

of

interventions
2.)

ctomy

exercises.

from

pain

as

of smooth muscles that causes A.) Pain scale of 1

87 | P a g e

RR: 23
Temp:
36.4
BP:

100/70
PR:79
CR: 85
Grimace
on the
face

graphy.

grimace in the face.

pain.

out of 5.

P
T

RATIONA

3.) Encourage ambulation or B.)

LE:

short walks.

R:

Pain is a
highly

To

Abdominal

guarding
promote

none

blood noted.

circulation and faster wound

healing.

C.) Grimace in the

subjective

face none noted.

state

in

which

4.) Administer analgesics as

variety

of

ordered.

unpleasan

R: Analgesics

synthesis

sensations

that causes pain.

of

inhibits

the

prostaglandin

and a wide
range

of

5.) Check vital signs.

distressing

R: Changes in the vital signs

factors

may

is

experienc

indicate

pain

and

discomfort.

e by the
sufferer.
Because

6.) Position client in Semi

88 | P a g e

the patient

Fowlers or High Fowlers

have

position.

undergone

R: May relieve pain and

post

enhance

cholecyste

decrease muscle tension.

circulation

and

ctomy, he
experienc

7.) Instruct the client to avoid

strenuous

presence

exercises.

of

R: To prevent bleeding from

discomfort

the incision cause by the

or

operation.

an

activities

and

uncomfort
able

8.) Advise to eat nutritious

sensation

food.

causing

R: To aide in strengthening of

the pain.

having

good

immune

system.
Bibliograp

9.) Increase Oral Fluid Intake.

hy:

R: In order to have a good

immune

system

against
89 | P a g e

Gradishar,

infection.

et.al
(2012).

10.)

Instruct

client

Pain.

watcher to report any signs of

Nursing

unusualities

Diagnosis

shortness of breath, pain in

Care

the incision site.

Plans.

R: To have the appropriate

Elsevier

interventions needed.

such

and
as

Inc.
Retrieved
June

30,

2015 from

ERICKA

FAITH

www1.us.e

CAMINS, St. N

lsevierheal
th.com

90 | P a g e

Name: SPJ

Age/Sex: 47 years old/ Male

Rm/Bed#: 306-2

Chief Complaint: Abdominal Pain;

Diagnosis: Cholelithiasis

Attending Physician: Dr. Gallardo

Post Open Cholecystectomy

Date

Cues

Nee

Diagnosis

Objective of Care

Interventions

Evaluation

and

Time
J

Impaired

At the end of my 8

1. Note odors.

Skin

hours span of care,

Rationale: Presence of foul

Integrity

the patient will be able smelling indicates infection.

-Post open

related to

to display

cholecystecto

surgery.

improvement in

2. Observe incisions

my

wound healing as

periodically, noting

-Subcostal

Incision Site

-VS:

Cholecyst

a. Absence of redness and resolution, and presence

intervention,

T: 35.1 c

ectomy- a

or erythema.

of bleeding and drainage.

patient was able to

surgical

Rationale: Verifies status of

display

Objective:

N
E
25,

Rationale: evidenced by:

June 24, 2015

@ 3PM
Goal Met

approximation of wound

Within my 8 hours

edges, hematoma formation

span of nursing

procedure

b. Absence of

healing, provides for early

improvement in

to remove

itchiness.

detection of developing

wound healing as

your

complications requiring

evidenced by:

gallbladde

c. Absence of purulent prompt evaluation and

AM

ra

discharge.

pear-

influencing choice of
interventions.

a. No redness
noted.
91 | P a g e

shaped

b. No

organ that

3. Assess pt.s room

sits just

temperature and humidity

below your

constant. Room temperature

liver on

should be kept close to 72

the upper

degrees and humidity at a low

right side

level unless otherwise

of your

ordered.

abdomen.

Rationale: Keeps skin cool

Your

and dry to prevent

gallbladde

perspiration

complained
itchiness
c. No purulent
discharges
noted.

r collects
and stores

4. Encourage frequent

bile a

positional change, inspect

digestive

pressure points, and

fluid

massage gently, asindicated.

produced

Rationale: Reduces pressure

in your

on skin, promoting peripheral

liver.

circulation and reducing risk

of skin breakdown.

Lewis, S.
(2012).

5. Palpate skin lesions for

92 | P a g e

Medical

size,shape,

Surgical

consistency,texture,temperatu

Nursing

re, and hydration

Critical

Rationale: Moisture or

Thinking

excoriation enhances growth

in Patient

of bacteria that can lead to

Care.

postoperative infection.

Elsevier
Mosby.

6. Provide routine incisional

US

care, being careful to keep

dressing dry and sterile.
Assess and maintain patency
of drains.
Rationale: Promotes healing.
Accumulation of drainage in
subcutaneous layers
increases tension on suture
line, may delay wound
healing, and serves as a
medium for bacterial growth.
7. Maintain good body
93 | P a g e

hygiene. Make sure the pt.

has at least a sponge bath
every day unless skin is too
dry.
Rationale: Promote self-care
and self-management to
prevent problem.
8. Provide pt. a peaceful and
quiet environment for resting
and healing.
Rationale: Promotes action

Gian Angelo C.

and effect of medication by

Ruiz, St. N

providing decreased stimuli.

Name: SPJ

Age/Sex: 47 years old/ Male

Rm/Bed#: 306-2

94 | P a g e

Chief Complaint: Abdominal Pain;

Diagnosis: Cholelithiasis

Attending Physician: Dr. Gallardo

Post Open Cholecystectomy

Date

Cues

Nee

and
Time
June

@
8 AM

Objective of Care

Interventions

Evaluation

d
Subjective:

Knowledg

regarding

appropriate

nagkasakit ko N

disease

care, the patient will

patient relationship.

sauna

process

manifest

2.) Evaluate

nagpadoctor

and

understanding of the

readiness or desire to

ko, human nay I

treatment

disease process and

learn.

tambal

related

25,
2015

Diagnosis

Katong

absence

nagkasakit

of

pila ka bulan, E

n.

nako

ang C

parehang

1.) Establish Rapport.

of

R: To gain patients trust

nursing

and have a good nurse-

10 AM

span

evidenced by:

Rationale:

A.) Participate

After 2 hours span

R: To determine level of of

in

patient manifested

3.) Assess motivation and understanding

and

B.) Initiate plans of

lifestyle

knowledge

changes

wala

nako T

is a state

participate

in

treatment

appropriate

information feasible to be nursing care, the

process;
Deficient

which

Goal Met

willingness of patient the

pero P
U

patients

learning

tambala

nagpacheck-

as

June 25, 2015

given at the moment.

informatio

lang R

my

to treatment

nasad ko mga P
gitumar

within

deficit hours

gihatag. Tapos, E
-

That

caregivers

disease

to process

learn.

of
and

treatment

as

R: Some patients are evidenced by:

and
in

ready to learn as soon

as they have
diagnosed;

been
others

A.) Participated
95 | P a g e

up,

as A

cognitive

regimen; and

cope better by denying

in

verbalized

by L

informatio

C.) Verbalization of

or delaying the need

process;

the patient.

Objective:

or

understanding

for instruction.

psychomot

about

or

disease

atmosphere of respect,

plans

required

process.

openness, trust, and

lifestyle

collaboration.

changes

skills

the

learning

4.) Provide

an

B.) Initiated

-Lack

of T

for health

source

of E

recovery,

R: This is very important

and

of

information

maintenan

when providing education

participate

-Asked

ce,

to patients with different

in treatment

health

values and belief about

regimen;

promotion

health and illness. Also,

and

condition

are

this will facilitate the flow Dili na kayo ko

-Expresses

lacking.

of the discussion.

questions
regarding

his

confusion

on

or

Due

to

5.) Assess

muinom og beer

history

of pati

the nature of

absence

the condition

of

R: To trace the source of Magpacheck-up

informatio

complication

n,

determine

-Failure
seek

to

medical

intervention

patient

believing

lacks

his

that

condition

the

gallstone formation.

necessary

what

development
disease.

sa

og

baboy.

and nasad ko inig naa

contributed
the

taba

mukaon

to
of

factors koy

gibati,

as

the verbalized.
the
C.) Verbalizatio
96 | P a g e

would

be

informatio

remedied

by

needed

6.) Be alert to signs of

avoidance

such

as

of

understandi

medication

for health

claiming to know the

ng

alone

recovery,

topic

the disease

maintenan

evading

change

ce

discussion

lifestyle

promotion.

-Failure

to

and

already

and
further

about

process.

a Ah.

certain topic.

about

Mao

nagasakit

diay
akong

R: May need to allow the tiyan inig muinom

Discontinuatio

Reference

patient

n of medication

consequences of lack of mukaon og taba.

without

Muzio,

knowledge before client is Kabalo

physicians

et.al

ready

order

(2012).

information.

Knowledg

7.) Discuss

-Took

him

years

before

realizing

the

urgency

of

submitting
himself
surgery

for

Deficit.

to

suffer

to

the ko

og

beer

og
nako

accept ngano,

as

verbalized.
patients

perception of need.

Nursing

R: Relate information to

Diagnosis

patients

Care

desires/needs and values

Plans.

or belief. To determine

Elsevier

what approach should be

Inc.

done to facilitate change.

Retrieved

8.) State objectives clearly

personal

97 | P a g e

June

30,

in learners term.

2015 from

R: To meet learners need

www1.us.e

according

to

level

of

lsevierheal

understanding.

Also,

to

th.com

avoid

confusion

and

misinterpretation.
9.) Participate in learning
process.
R: To assess the learning
of the patient and correct
the wrong belief of the
patient.
10.)

Teach

patient

about infection control.

R:

Since

undergone
preventive

patient
a

have

surgery,
measures

should be taken in order

to avoid development of
Name: SPJ

complications.
Age/Sex: 47 years old/ Male
Rm/Bed#: 306-2

Chief Complaint: Abdominal Pain;

Diagnosis: Cholelithiasis

Dewy Escueta, STN

Attending Physician: Dr. Gallardo

Post Open Cholecystectomy

98 | P a g e

Date

Cues

Nee

and
Time
June

Diagnosis

Objective of Care

Interventions

Evaluation

d
Objective:

25,

Risk for

Within my 8-hour

Infection

span of care, the

1. Establish rapport
Rationale: to facilitate

-Vital signs:

related to

patient will be able to

Temp: 36.4c

inadequat

maintain infection-

7 am

RR: 23

e primary

free, as evidenced by: 2. Monitor vital signs of the

CR:85

defense(br

PR:79

oken skin)

BP:100/70

secondaryA. Normal range of vital

-with post-op

to

dressing dry

intraoperat

and intact.

ive

-with

cholangiog

B. Post-Op dressing

@ 3pm

cooperation and reduce

2015

signs:
T: 36.5-37.5 C
CR: 70-80 bpm
RR: 16-20 cpm
BP: 100/70-120/90

June 26, 2015

apprehension.

GOAL MET!

patient.
Rationale: to obtain clients

After my 8-hour

baseline VS for future

span of care, the

comparison, and to assess

patient was able to

for the signs of infection

maintain infection-

such as increased

free, aeb:

temperature.

sulbactam/amp M

ram

3. Emphasize constant and

icillin as

cholecyste

remains intact and

proper hand hygiene by all

prophylaxis

ctomy

dry.

caregivers and also the

Rationale:

Risk for

infection

means at

risk for

A. Vital signs of:

patient
Rationale: it serves as a first

C. Identify interventions
to prevent or reduce
risk of infection.

line of defense against

Temp: 36.4
CR:81
PR:78
BP:110/70
RR: 18

infection.
4. Maintain aseptic technique
99 | P a g e

being

with any procedures, such

invaded by

as routine would care and

pathogeni

changing of dressing.
Rationale: Prevent spread of
bacteria reducing risk of

B. The post-op
and dry.
C. Patient was able to

organisms

. In

Cholecyst

ectomy,

note for any presence of any

there is

discharges and unusualities.

Rationale: Early detection of

removal of
the
gallbladder
. It
involves
the
incision at
the right
subcostal.
After the
surgery,
this
incision

remained intact

nosocomial infection
5. Inspect dressing and wound:

identify
interventions to
reduce risk for
infections, as
evidenced by the

developing of infection

verbalization,

provides opportunity for

kanangmaghugas

timely intervention and

ugkamotugdilema

prevent of more serious

gpasingot para

complications

walaykomplikasyo

6. Keep area around wound

n.

clean and dry.

Rationale: wet and moist
area around the wound
could lodge bacterial growth.
7. Instruct to splint when
coughing.
Rationale:To minimize pain
100 | P a g e

makes the

while moving and coughing.

risk of
getting a
bacterial
skin
infection
much
higher.

8. Instruct to wear loose-fitting

clothes.
Rationale: sweat can
facilitate the growth of
bacteria.
9. Encourage patient to eat rich

Breaks in

in protein foods such as fish,

the skin

chicken and etc, as

integrity,

tolerated.
Rationale: High in protein

particularly
those that
inoculate
pathogens
into the
dermis,
frequently
cause or
exacerbat
e skin

foods promotes faster

healing of the wound.
10. Emphasized necessity of
taking antibiotics as ordered.
Rationale: Premature
discontinuation of treatment
when client begins to feel
well may result in return of
infection

infections.
101 | P a g e

The most
common
cause is
the
Staphyloc
occus
aureus
which may
cause
impetigo,
ecthyma
and
folliculitis.
Bibliograp
hy:
Dryden,
M.S.
(2010).
Complicat
ed Skin
and Soft
102 | P a g e

Tissue
Infection.
Journal of
Antimicrob
ial
Chemothe
rapy,
65(10),
35-44.

Ivannah Zerna,
StN
Name: SPJ

Age/Sex: 47 years old/ Male

Rm/Bed#: 306-2

Chief Complaint: Abdominal Pain;

Diagnosis: Cholelithiasis

Attending Physician: Dr. Gallardo

Post Open Cholecystectomy

Date
and

Cues

Nee

Diagnosis

Objective of Care

Interventions

Evaluation

d
103 | P a g e

Time
J

Subjective:

Risk for

At the end of my 8

1. Assess patients level of

June 24, 2015 @

Bawal pa pud

imbalance

hours span of care,

capabilities of the situation.

3PM

ko mukaon,

d nutrition

the patient will be able R: To know clients ability to

as verbalized

related to

to demonstrate

by the patient.

inadequat

understanding of

e bile

dietary needs as

2. Emphasize importance of

Objective:

secretion

evidenced by:

low fat diet and small frequent Within my 2 hours

-Post

secondary

cholecystecto

to

my

A
L

24,

Goal Partially
Met

meals.

span of nursing

a. Verbalization of

R: Low fat diet limits need for

intervention,

cholecyste

understanding of

bile production and reduces

patient was able to

ctomy.

prescribed diet.

discomfort associated with

consume his low

inadequate digestion of fats.

fat meal during

-NPO
@

cope with the condition.

R:

b. Adequacy of

-Abdominal

Gallbladde

energy levels and

Pain

lunch time and

3. Instruct to avoid intake of

verbalized of

r serves as tolerance of the diet.

fatty foods such as fried

having enough

a reservoir

foods.

food and energy

-Hyperactive

for bile

c. No signs of

R: Fatty foods needs large

for the day.

bowel sounds

while its

dehydration,

amount of bile to digest.

not being

weakness, and

-VS:

used for

fatigue.

T: 35.1 c,

digestion.

feeding and avoid large

It functions

heavy meals especially at

AM

RR: 21cpm,

4. Introduce a small frequent

104 | P a g e

CR: 64 bpm,

to store

night.

PR: 60 bpm,

bile. Bile

R:Small frequent feeding

BP: 110/70

breaks up

requires small amount of bile

mmHg

fatty acids

upon digestion.

and drains
waste to

5. Encourage to eat high fiber

duodenum

foods such as black beans,

oatmeals, and pineapples.

When food

R: To avoid constipation

enters the
small

6. Instruct to avoid use of

intestine,

alcoholic beverages.

cholecysto

R: To minimizes risk for

kinin is

pancreatic involvement.

released,
signaling

7. Ambulate and increase

the

activity as tolerated.

gallbladde

R: Helpful in expulsion of

r to

flatus, reduction of abdominal

contract

distension. Contributes to

and

overall recovery and sense of

secrete

well-being and decreases

105 | P a g e

bile into

possibility of secondary

the small

problems related to

intestine

immobility

through
the
common

8. Explain purpose of activity

bile duct.

restrictions and need for

When the

balance between activity/rest.

gallbladde

R: Rest reduces oxygen and

r is gone,

nutrient needs of

bile flows

compromised tissues.

directly

Balancing rest with activity

from the

prevents exhaustion and

liver into

impairment of cellular

the small

perfusion.

intestine
causing

9. Provide a pleasant

alteration

atmosphere at mealtime.

in

R: It is useful in promoting

digestion.

appetite and reduces nausea.

Lewis, S.

10. Administer to follow up

106 | P a g e

(2012).

IVF as ordered.

Medical

R: To provide nutrition to the

Surgical

patient and access for

Nursing

medications.

Critical
Thinking
in Patient
Care.
Elsevier
Mosby.

Michelle Anne C.

US

Sabio, St. N

107 | P a g e