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Cues/Needs Nursing Rationale Goals and Nursing Rationale Evaluation

Diagnosis Objectives Interventions


After 30 minutes of -Assess pain, character, -Pain assessment can After 30 minutes of
Subjective: Acute pain Unpleasant sensory nursing location, severity, provide clues about nursing
“kumikirot kirot related to post and emotional interventions, the precipitating and diagnosis; used to interventions, the
yun opera sakin” operative experience arising from patient will: relieving factors and determine treatment goal was met as the
as verbalized by incision actual tissue damage duration; use a pain required. patient able to:
the patient. secondary to through incision or rating scale.
laparoscopic breaking of skin, -Report pain -Report moderate
Objective: cholecystecto especially abdominal alleviation from - Encourage use of pain of 3/10
my. layers. severe pain 8/10, to relaxation - Promotes rest,
-Pain scale: 8/10 A- delta myelinated moderate pain 3- technique. redirects
(10 as the highest) fiber perceive a 4/10, or totally attention, may
-Facial grimace sharp pain when relieved from pain. enhance
-Guarding noxious thermal or coping. -Identify and use
behavior over the - Identify and use -Have the patient splint appropriate
mechanical
abdomen appropriate incision when moving -Helps to provide support interventions to
-Restlessness
stimulation occurs. interventions to to the incision and manage pain and
-Pupillary dilation When mechanical manage pain and decrease pain. Splinting discomfort
stimuli activate the discomfort. provides incision support/
V/S unmyelinated C fiber, decreases muscle tension -Appeared relaxed,
BP: 130/90 mmHg the cutaneous pain is - Appear relaxed, to promote cooperation able to rest/ sleep
PR: 87 felt as long lasting, able to rest/ sleep -Encourage use of with therapeutic regimen and participate in
RR: 25 burning pain or sharp and participate in alternative methods of activities
T: 37 pain activities pain relief such as -Relaxation exercise: appropriately
appropriately relaxation exercises technique used to bring
(deep-breathing about a state of physical
exercise), massage and and mental awareness
References: distraction. and tranquility. Massage:
decreases muscle tension
M.Doenges and can
M. moorhouse promote comfort.
A.Murr Distraction: heightening
Nanda p.498 one’s concentration upon
non painful stimuli to
Focus on develop one’s awareness
pathophysiology by: -Promote bed rest and and experience of pain.
in low fowler’s position
Barbara Bullock
-Bed rest in low
Reet L. Henze fowler’s position
p. 1053 reduces intra
abdominal
pressure.

-Control
environmental
Cues/Needs Nursing Rationale Goals and Nursing Rationale Evaluation
Diagnosis Objectives Interventions

Subjective Ineffective Due to the pain felt After 30 minutes of -Administer oxygen -For management of After 30 minutes of
Data breathing after the nursing intervention, at the lowest underlying pulmonary nursing
“Nahihirapan ako pattern related laparoscopic the client will be concentration. condition, respiratory intervention, the
huminga lalo na to pain on post cholecystectomy able to establish a distress or cyanosis. goals are met as
normal effective
pag kumikirot operative site operation, there is a evidence by
respiratory pattern
yun sakin sa tyan decreased lung -Elevate head of -To promote establishing a
ko” as verbalized expansion and bed, place client in physiological/ normal/ effective
by the patient. decreased respiratory semi-fowlers psychological ease of respiratory pattern
depth/vital capacity position. maximal inspiration. with respiratory
Objective data that causes rate of 20cpm and
inadequate -Encourage slower -To assist client in oxygen saturation
Unable to ventilation for the deeper respiration ‘taking control’ of the of 100 percent.
breathe normally client . with the use of situation.
pursed lip
Cold both upper technique and
and lower deep breathing
extremities exercise.
-To verify the
RR- 24 cpm -Monitor the pulse improvement and
O2 Saturation- oximeter maintenance of oxygen
88 percent saturation.
-Encourage
adequate rest -To limit fatigue.
period between
Reference: NANDA activities
Edition 11 p. 143 -To promote deeper
-Administer respiration
medication
prescribed by the
physician such as
analgesics.
Cues/Needs Nursing Rationale Goals and Nursing Rationale Evaluation
Diagnosis Objectives Interventions

Subjective: Impaired skin An invasive procedure After 4 hours of -Monitor surgical site -Early identification of poor After 4 hours of
“May tahi ako sa integrity related makes an open incision nursing intervention, for any signs and wound healing or infection nursing intervention,
tyan dahil sa to surgical on an area of the body the patient will symptoms of infection. can expedite treatment. the goal is fully met
opera ko minsan to allow a clear view of remain free from as evidenced by
incision on
kumakati sya pero the underlying or the infection and patient remained
iniiwasan kong abdomen organs underneath the bleeding. free from infection
makamot” as secondary to skin and may be a -Apply pressure to the -Establish hemostasis, and and did not exhibit
verbalized by the laparoscopic therapeutic approach to incision site prevents bleeding excessive bleeding.
patient. cholecystectomy allow drainage of
. discharges on the - Maintaining clean, dry
Objective: operative site. skin provides a barrier to
- Demonstrated good infection. Patting skin
- Ruptured skin skin hygiene, ( wash
- Facial grimace dry instead of rubbing
thoroughly and pat dry reduces risk of dermal
- Incision
- Disruption of the skin surrounding the trauma to fragile skin
skin surface wound carefully)
- Presence of -maintenance of clean
sutures - change dressings on incision site decreases
incision and over number of organisms
drainage tube and reduces chance of
insertion sites, or infection.
puncture sites. Clean
Reference: area using sterile
p. 778-780 technique.
Nursing care plans
- Improved nutrition and
guidelines for
- Emphasized hydration will improve
individualizing patient
care, 6th ed importance of skin condition
By: Doenges adequate fluid intake.
-Adequate nutrient
intake, especially of
-Encourage adequate vitamin C, protein and
nutritional intake, iron, is required for
especially of protein, healing and tissue
vitamin C and iron. repair.

-The drainage device


-Maintain patency of helps prevent
Cues/Needs Nursing Rationale Goals and Nursing Rationale Evaluation
Diagnosis Objectives Interventions
Subjective Pain impairs mobility Pain impairs -Change position -Mobility aids can
Data: Impaired and activity. Full mobility and frequently when on increase level of After 8 hours of
physical function may be activity. Full bedrest; support mobility. nursing
“Nahihirapan ako mobility affected and be function may be affected body parts or intervention, the
gumalaw dahil sa related to pain delayed. affected and be joints with pillows. the goal was half
tahi ko sa tayan, at incision site Source: delayed. met as evidenced
kumikirot kase Source: - Encourage -To permit maximal by : client:
madalas eh.” appropriate use of effort or involvement in
Monks. Home assistive devices in activity. 1. Refused to do
health nursing: the home setting. other activites
Objective Data: assessment and because of fear to
care planning. -Provide skin -Decreases discomfort, experience pain
- Limited range of Elsevier Health massage. Keep skin maintains muscle after the activity.
motion. Sciences, 2002 clean and dry well. strength/ joint mobility,
- not able to Keep linens dry and enhances circulation 2. has no
move freely. wrinkle-free. and prevents skin contractures and
- slowed breakdown. complications
movement. observed after an 8
- Pain scale of hour care.
8/10 -Encourage deep -Stimulates circulation
breathing and and prevents skin
coughing. Elevate irritation.
head of bed Turn side Mobilizes secretions,
to side. improves lung
expansion and reduces
risk of respiratory
Reference: complications.
Monks. Home health -Encourage early
nursing: assessment ambulation. Support -Early ambulation
and care planning. abdomen when prevents postop
Elsevier Health ambulating. complications. Splinting
Sciences, 2002 provides incisional
support/ decreases
muscle tension to
promote cooperation
with therapeutic
regimen.
Provide adequate rest
periods in between
activities.

- Provide safe
environment such as
giving assistance in
sitting and
transferring from bed -Avoids accidental
to chair or chair to injuries and falls.
bed and use of
wheelchair if possible.

-Encourage patient to
discuss feelings and
concerns about her -To prevent anxiety and
altered state of promote compliance
mobility
Cues/Needs Nursing Rationale Goals and Nursing Rationale Evaluation
Diagnosis Objectives Interventions
Subjective: Deficient Laparoscopic After 1- 2 hours of After 1- 2 hours of
“ano ba yun knowledge Cholecystectomy is interventions, the interventions, the
mga dapat kong the surgical removal patient will be able - Assess readiness of -The patient must be goal was fully met,
about self care to verbalize an
gawin pagkatpos of the infected gall patient to learn motivated to learn, have patient was able
activities r/t understanding of (motivation, cognitive the capability to learn the
ng operasyon bladder. to verbalize an
incision care, the operative level , and content, and be free of
ko” as procedure and
understanding of
verbalized by dietary The client has a physiological status). distractions fro learning, the operative
prescribed post-
the client. modifications, deficiency of operative regimens. such as pain and procedure and
medications cognitive information emotional distress. prescribed post-
References: reportable related to specific operative
signs and topic such as self regimens.
M.Doenges care activities about
symptoms - Create a quiet - Environmental noise can
M. moorhouse incision care, dietary “Kailangan pala
A.Murr environment conducive prevent the learner from
modification, and to learning. sundin yun mga
Nanda p.498 focusing on what is being
prognosis and instructions doctor
discharge plan. taught. para mas
Presence of
mapadali yung
incision on the
pagrecover ko” as
abdomen due to
- Due to the short verbalized bythe
post-operative Teach the patient
hospital stay following patient.
done wound care and
infection control cholecystectomy, the
measures: patient is at home when
− Keep incision postoperative infections
clean and dry. occur, so it is crucial
− If dressing is that the patient know
applied, change signs of infection,
using aseptic understanding the
technique. rationale for these
− Monitor for interventions will
signs of
infection at enhance the patient’s
incision site willingness to comply
and drain with limitations.
insertion site:
warmth,
redness,
purulent
drainage, and
increased pain.
− Monitor
temperature for
elevations.
IX. LIST OF PRIORITY OF PROBLEM

1. Ineffective breathing pattern related to pain on post operative


site

2. Acute pain related to post operative incision secondary to


laparoscopic cholecystectomy.

3. Impaired skin integrity related to surgical incision on abdomen


secondary to laparoscopic cholecystectomy.

4. Impaired physical mobility related to pain at incision site

5. Deficient knowledge about self care activities r/t incision care,


dietary modifications, medications reportable signs and
symptoms Legend: #1- being the highest priority
#5- being the last priority