Nursing CareA.) NURSING CARE PLANName: SPJAge/Sex: 47 years old/ MaleRm/Bed#: 306-2Chief Complaint: Abdominal Pain;Diagnosis: CholelithiasisAttending Physician: Dr. GallardoPost Open CholecystectomyDate and TimeCuesNeedDiagnosisObjective of CareInterventionsEvaluation

June 25, 2015@10 amSUBJECTIVE:Mga 4 out of 5 sa pain scale ninyo gang. As verbalized by the patient.

OBJECTIVE: Abdominal guarding 7am VS:RR: 23Temp: 36.4BP: 100/70PR:79CR: 85 Grimace on the faceCOGNITIVE

PERCEPTUAL

PATTERNAcute pain related to subcostal suture secondary to post open cholecystectomy with Intraoperative Cholangiography.

RATIONALE:

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors is experience by the sufferer. Because the patient have undergone post cholecystectomy, he experience presence of discomfort or an uncomfortable sensation causing the pain.

Bibliography:

Gradishar, et.al (2012). Pain. Nursing Diagnosis Care Plans. Elsevier Inc. Retrieved June 30, 2015 from www1.us.elsevierhealth.comAfter 1 hour of nursing interventions patient will experience relief from pain as evidenced by:

A.) Pain Scale of 0 2 out of 5.

B.)Absence of abdominal guarding.

C.) Absence of grimace in the face.1.) Assess for the site which pain is felt.R: Unrelieved pain can create more problems such as anxiety, anger, and other respiratory that may cause the delay of wound healing.

2.) Encourage and assist client to do deep breathing exercises.R: Deep breathing exercises can enhance relaxation to the smooth muscles that causes pain.

3.) Encourage ambulation or short walks.R: To promote blood circulation and faster wound healing.

4.) Administer analgesics as ordered.R: Analgesics inhibits the synthesis of prostaglandin that causes pain.

5.) Check vital signs.R: Changes in the vital signs may indicate pain and discomfort.

6.) Position client in Semi Fowlers or High Fowlers position.R: May relieve pain and enhance circulation and decrease muscle tension.

7.) Instruct the client to avoid strenuous activities and exercises.R: To prevent bleeding from the incision cause by the operation.

8.) Advise to eat nutritious food.R: To aide in strengthening of having a good immune system.

9.) Increase Oral Fluid Intake.R: In order to have a good immune system against infection.

10.) Instruct client and watcher to report any signs of unusualities such as shortness of breath, pain in the incision site.R: To have the appropriate interventions needed.June 25, 2015@ 11am

Goal Met

After 1 hour of nursing interventions patient experienced relief from pain as evidence by:

A.) Pain scale of 1 out of 5.

B.) Abdominal guarding none noted.

C.) Grimace in the face none noted.

ERICKA FAITH CAMINS, St. N

Name: SPJAge/Sex: 47 years old/ MaleRm/Bed#: 306-2Chief Complaint: Abdominal Pain;Diagnosis: CholelithiasisAttending Physician: Dr. GallardoPost Open CholecystectomyDate and TimeCuesNeedDiagnosisObjective of CareInterventionsEvaluation

JUNE

25,

2015

@

8AM

Objective:

-Post open cholecystectomy-Subcostal Incision Site-VS:T: 35.1 c

NUTRITIONAL

METABOLIC

Impaired Skin Integrity related to surgery.

Rationale:

Cholecystectomy- a surgical procedure to remove your gallbladder a pear-shaped organ that sits just below your liver on the upper right side of your abdomen. Your gallbladder collects and stores bile a digestive fluid produced in your liver.

Lewis, S. (2012). Medical Surgical Nursing Critical Thinking in Patient Care. Elsevier Mosby. US

At the end of my 8 hours span of care, the patient will be able to display improvement in wound healing as evidenced by:

a. Absence of redness or erythema.

b. Absence of itchiness.

c. Absence of purulent discharge.1. Note odors.Rationale: Presence of foul smelling indicates infection.

2. Observe incisions periodically, noting approximation ofwound edges, hematoma formation and resolution, and presence of bleeding and drainage.Rationale: Verifies status of healing, provides for early detection of developing complications requiring prompt evaluation and influencingchoice of interventions.

3. Assess pt.s room temperature and humidity constant.Room temperature should be kept close to 72 degrees and humidity at a low level unless otherwise ordered.Rationale: Keeps skin cool and dry to prevent perspiration

4. Encourage frequent positional change, inspect pressure points, and massage gently, asindicated.Rationale: Reduces pressure on skin, promoting peripheral circulation andreducing risk ofskin breakdown.

5. Palpate skin lesions for size,shape, consistency,texture,temperature, and hydrationRationale: Moisture or excoriation enhances growth of bacteria that can lead to postoperative infection.

6. Provide routine incisional 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, andserves as a medium for bacterial growth.

7. Maintain good body 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 and effect of medication by providing decreased stimuli.

June 24, 2015 @ 3PM

Goal Met

Within my 8 hours span of nursing intervention, patient was able to display improvement in wound healing as evidenced by:

a. No redness noted.b. No complained itchinessc. No purulent discharges noted.

Gian Angelo C. Ruiz, St. N

Name: SPJAge/Sex: 47 years old/ MaleRm/Bed#: 306-2Chief Complaint: Abdominal Pain;Diagnosis: CholelithiasisAttending Physician: Dr. GallardoPost Open CholecystectomyDate and TimeCuesNeedDiagnosisObjective of CareInterventionsEvaluation

June 25, 2015

@

8 AMSubjective:

Katong nagkasakit ko sauna nagpadoctor ko, human nay tambal gihatag. Tapos, nagkasakit nasad ko mga pila ka bulan, gitumar lang nako ang parehang tambala pero wala nako nagpacheck-up, as verbalized by the patient.

Objective:

-Lack of source of information-Asked questions regarding his condition-Expresses confusion on the nature of the condition-Failure to seek medical intervention believing that his condition would be remedied by medication alone-Failure to change lifestyle-Discontinuation of medication without physicians order-Took him 3 years before realizing the urgency of submitting himself for surgeryCOGNITIVE-PERCEPTUAL

PATTERNKnowledge deficit regarding disease process and treatment related to absence of information.

Rationale: Deficient knowledge is a state in which cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion are lacking. Due to absence of information, the patient lacks the necessary information needed for health recovery, maintenance and promotion.

Reference:Muzio, et.al (2012). Knowledgd Deficit. Nursing Diagnosis Care Plans. Elsevier Inc. Retrieved June 30, 2015 from www1.us.elsevierhealth.comThat within my 2 hours span of appropriate nursing care, the patient will manifest understanding of the disease process and treatment as evidenced by:

A.) Participate in learning process;B.) Initiate plans of lifestyle changes and participate in treatment regimen; andC.) Verbalization of understanding about the disease process.1.) Establish Rapport.R: To gain patients trust and have a good nurse-patient relationship.2.) Evaluate patients readiness or desire to learn.R: To determine level of information feasible to be given at the moment.3.) Assess motivation and willingness of patient and caregivers to learn.R: Some patients are ready to learn as soon as they have been diagnosed; others cope better by denying or delaying the need for instruction.4.) Provide an atmosphere of respect, openness, trust, and collaboration.R: This is very important when providing education to patients with different values and belief about health and illness. Also, this will facilitate the flow of the discussion.5.) Assess history of gallstone formation.R: To trace the source of complication and determine what factors contributed to the development of the disease.6.) Be alert to signs of avoidance such as claiming to know the topic already and evading further discussion about a certain topic.R: May need to allow the patient to suffer the consequences of lack of knowledge before client is ready to accept information.7.) Discuss patients perception of need.R: Relate information to patients personal desires/needs and values or belief. To determine what approach should be done to facilitate change.8.) State objectives clearly in learners term.R: To meet learners need according to level of understanding. Also, to 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 patient have undergone a surgery, preventive measures should be taken in order to avoid development of complications.June 25, 2015@10 AM

Goal Met

After 2 hours span of appropriate nursing care, the patient manifested understanding of the disease process and treatment as evidenced by:

A.) Participated in learning process;

B.) Initiated plans of lifestyle changes and participate in treatment regimen; andDili na kayo ko muinom og beer pati mukaon og taba sa baboy. Magpacheck-up nasad ko inig naa koy gibati, as verbalized.

C.) Verbalization of understanding about the disease process.Ah. Mao diay nagasakit akong tiyan inig muinom ko og beer og mukaon og taba. Kabalo nako ngano, as verbalized.

Dewy Escueta, STN

Name: SPJAge/Sex: 47 years old/ MaleRm/Bed#: 306-2Chief Complaint: Abdominal Pain;Diagnosis: CholelithiasisAttending Physician: Dr. GallardoPost Open CholecystectomyDate and TimeCuesNeedDiagnosisObjective of CareInterventionsEvaluation

June 25, 2015@7 am

Objective:

-Vital signs:Temp: 36.4cRR: 23CR:85PR:79BP:100/70-with post-op dressing dry and intact.-with sulbactam/ampicillin as prophylaxis

NUT R I T I O N A L-METABO LI C

PATTERNRisk for Infection related to inadequate primary defense(broken skin) secondary to intraoperative cholangiogram cholecystectomyRationale:Risk for infection means at risk for being invaded by pathogenic organisms. In Cholecystectomy, there is removal of the gallbladder. It involves the incision at the right subcostal. After the surgery, this incision makes the risk of getting a bacterial skin infection much higher. Breaks in the skin integrity, particularly those that inoculate pathogens into the dermis, frequently cause or exacerbate skin infections. The most common cause is the Staphylococcus aureus which may cause impetigo, ecthyma and folliculitis.

Bibliography:Dryden, M.S. (2010). Complicated Skin and Soft Tissue Infection. Journal of Antimicrobial Chemotherapy, 65(10), 35-44.

Within my 8-hour span of care, the patient will be able to maintain infection-free, as evidenced by:

A. Normal range of vital signs:T: 36.5-37.5 CCR: 70-80 bpmRR: 16-20 cpmBP: 100/70-120/90

B. Post-Op dressing remains intact and dry.

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

1. Establish rapportRationale: to facilitate cooperation and reduce apprehension.

2. Monitor vital signs of the patient. Rationale: to obtain clients baseline VS for future comparison, and to assess for the signs of infection such as increased temperature.

3. Emphasize constant and proper hand hygiene by all caregivers and also the patientRationale: it serves as a first line of defense against infection.

4. Maintain aseptic technique with any procedures, such as routine would care and changing of dressing.Rationale: Prevent spread of bacteria reducing risk of nosocomial infection

5. Inspect dressing and wound: note for any presence of any discharges and unusualities.Rationale: Early detection of developing of infection provides opportunity for timely intervention and prevent of more serious complications

6. Keep area around wound 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 while moving and coughing.

8. Instruct to wear loose-fitting clothes.Rationale: sweat can facilitate the growth of bacteria.

9. Encourage patient to eat rich in protein foods such as fish, chicken and etc, as tolerated.Rationale: High in protein 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

June 26, 2015@ 3pmGOAL MET!

After my 8-hour span of care, the patient was able to maintain infection-free, aeb:A. Vital signs of: Temp: 36.4CR:81PR:78BP:110/70RR: 18

B. The post-op remained intact and dry.C. Patient was able to identify interventions to reduce risk for infections, as evidenced by the verbalization, kanangmaghugasugkamotugdilemagpasingot para walaykomplikasyon.

Ivannah Zerna, StN

Name: SPJAge/Sex: 47 years old/ MaleRm/Bed#: 306-2Chief Complaint: Abdominal Pain;Diagnosis: CholelithiasisAttending Physician: Dr. GallardoPost Open CholecystectomyDate and TimeCuesNeedDiagnosisObjective of CareInterventionsEvaluation

JUNE

24,

2015

@

8AM

Subjective:Bawal pa pud ko mukaon, as verbalized by the patient.

Objective:-Post cholecystectomy

-NPO

-Abdominal Pain

-Hyperactive bowel sounds

-VS:T: 35.1 c, RR: 21cpm, CR: 64 bpm,PR: 60 bpm,BP: 110/70 mmHg

NUTRITIONAL

METABOLIC

Risk for imbalanced nutrition related to inadequate bile secretion secondary to cholecystectomy.

R: Gallbladder serves as a reservoir for bile while its not being used for digestion. It functions to store bile. Bile breaks up fatty acids and drains waste to duodenum.When food enters the small intestine, cholecystokinin is released, signaling the gallbladder to contract and secrete bile into the small intestine through the common bile duct. When the gallbladder is gone, bile flows directly from the liver into the small intestine causing alteration in digestion.

Lewis, S. (2012). Medical Surgical Nursing Critical Thinking in Patient Care. Elsevier Mosby. US

At the end of my 8 hours span of care, the patient will be able to demonstrate understanding of dietary needs as evidenced by:

a. Verbalization of understanding of prescribed diet.

b. Adequacy of energy levels and tolerance of the diet.

c. No signs of dehydration, weakness, and fatigue.1. Assess patients level of capabilities of the situation. R: To know clients ability to cope with the condition.

2. Emphasize importance of low fat diet and small frequent meals.R: Low fat diet limits need for bile production and reduces discomfort associated with inadequate digestion of fats.

3. Instruct to avoid intake of fatty foods such as fried foods.R: Fatty foods needs large amount of bile to digest.

4. Introduce a small frequent feeding and avoid large heavy meals especially at night.R:Small frequent feeding requires small amount of bile upon digestion.

5. Encourage to eat high fiber foods such as black beans, oatmeals, and pineapples.R: To avoid constipation

6. Instruct to avoid use of alcoholic beverages.R: To minimizes risk for pancreatic involvement.

7. Ambulate and increase activity as tolerated.R: Helpful in expulsion of flatus, reduction of abdominal distension. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility

8. Explain purpose of activity restrictions and need for balance between activity/rest.R: Rest reduces oxygen and nutrient needs of compromised tissues. Balancing rest with activity prevents exhaustion and impairment of cellular perfusion.

9. Provide a pleasant atmosphere at mealtime.R: It is useful in promoting appetite and reduces nausea.

10. Administer to follow up IVF as ordered.R: To provide nutrition to the patient and access for medications.June 24, 2015 @ 3PM

Goal Partially Met

Within my 2 hours span of nursing intervention, patient was able to consume his low fat meal during lunch time and verbalized of having enough food and energy for the day.

Michelle Anne C. Sabio, St. N

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