NURSING CARE PLAN September 6, 2011 Assessment

Planning

Intervention

Expected Outcomes After 30 minutes to 1 hour of proper nursing intervention, the patient demonstrated relief of pain from 8/10 to 4/10.

S: Masakit ang sugat ko Within 30 minutes to 1 as verbalized by the hour of proper nursing patient P/S of 8/10 intervention, the patient will demonstrate relief of pain from 8/10 to 4/10. O:  grimace when moving  guarding behavior protecting the RUQ of abdomen  irritable  presence of rebound  with incision at RUQ  abdominal tenderness Nursing diagnosis Acute pain related to post operative surgical incision

 Instruct the patient in deep breathing pattern every time pain occurs by inhaling via nose and exhaling via mouth. It produces soothing, relaxing and pleasure inducing alpha brainwaves, calms the excitatory neurotransmitters and stress response system and thus help to relieves anxiety, stress and pain.  Assist in comfortable position To promote comfort.  Provide comfort measures such as back rubbing. Back massage relieves muscle tension, promotes physical and mental relaxation, and helps relieves pain .  Provide quiet environment and calm activities to provide comfort and prevent fatigue  Provide diversional activities like having a therapeutic communication to her. To reduce tension that is occurring, thus reduce intensity of pain.

Scientific Explanation Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute

 Encourage adequate rest periods to regain loss of energy due to untolerated of pain

pain on the right part of the abdomen.

 Advise to wear loose, light and clean clothing. to prevent irritation and for the patient to feel comfortable

September 6, 2011 Assessment

Planning

Intervention

Expected Outcomes

S> Hindi ako makagalaw ng maayosas verbalized by the patient O>    

Limited body movement Exertional discomfort Inability physical ability Difficulty turning from side to side

Within 8 hours of proper nursing intervention the patient will be able to participate in desired activities.

Nursing diagnosis: Activity intolerance related to muscle weakness secondary to post surgical incision Scientific explanation Insufficient physiological or psychological energy to endure or complete or derived daily activity.

 Adjust activities. Reduce intensity level of activity or discontinue activities that cause undesired physiological changes Prevents the patients overexertion  Increase exercise gradually, such as stopping to rest for 3 minutes Preserves conservation of energy  Perform active or passive ROM exercises to all extremities every 2 to 4 hours This exercises foster muscle strength and tone, maintain joint mobility and prevent contractures.  Provide positive atmosphere while acknowledging difficulty of the situation of the client Helps minimize frustration and conserves energy  Assist with activities and provide clients use of assistive devices Protects the client from injury  Promote comfort measures such as back rubbing Gives the chance for the client to enhance ability to participate in activities  Encourage to maintain positive attitude and suggest use of relaxation techniques such as visualization guided imagery as

After 8 hours of proper nursing intervention, the patient will be able to participate in desired activities, as evidenced by performing passive ROM exercises and turning from side to side on the bed.

appropriate To enhance sense of well being  Support affected body part To maintain position and reduce risk of pressure  Provide emotional support and offer positive feedback when patient displays initiative To help improve patients self concept and motivation to improve ADLs.

September 6, 2011 Assessment

Planning

Intervention

Expected Outcomes

S> O    

With post operative incision WBC: 14.6 g/L Dirty nails Jaundice

Within 1-2 hours of proper nursing interventions the patient will identify intervention to prevent or reduce risk of infection.

 Cleanse incision daily as necessary with povidone iodine or other appropriate solutions. It will prevent the spread of microorganism.  Use appropriate hand washing technique. Handwashing reduces the risk for infection.  Instruct to promptly report sign and symptoms of infection such as redness, warmth, swelling and increase body temperature. 2/3 of wound infection occurs after surgery or discharge.  Carefully wash and pat dry skin use hydration and moisturization on all at risk surfaces. it will prevent the growth of bacteria  Advise to clean the IFC tube and do perineal care everyday To reduce and prevent growth of bacteria.  Watch the incision site for color, healing, and presence of drainage A fresh, healing incision site is a port of

After 1-2 hours of proper nursing intervention the patient should identify intervention to prevent or reduce risk of infection as evidenced by his discussion in wound care.

Nursing diagnosis: Risk for infection r/t inadequate primary defense secondary traumatized tissue. Scientific explanation At increase risk for being invaded pathogenic organism.

entry for bacteria  Demonstrate and allow return demonstration of wound care. To know if the patient really understand the principle of proper wound care.

September Assessment

Planning

Intervention

Expected Outcomes

S> O> Nursing diagnosis: Scientific explanation