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Assessment

Nursing Diagnosis Alteration in comfort related to inflammation and distortion of tissue where?? What kind of tissue, location???

Scientific Rationale

Planning

Nursing Intervention

Rationale

Evaluation

SUBJECTIVE: Masakit ang tagiliran ko what else as verbalized by the patient P- when moving and at rest Q- sharp pain R-back of the body S-9/10 T-Continuous pain OBJECTIVE:

BASE TO PATHO

After 15 to 30 mins of nursing interventions, the patient pain will be relieve from pain.

-Administer ketorolac 30mg IV as ordered by the physician - Promote bed rest, and in low fowlers position.

-to relieve the pain


- Bed rest in low fowlers position reduces intra abdominal pressure. - Reduces Irritation

- Use soft Linens.

After 15 to 30 mins of nursing intervention the patient was relieved from pain . As evidence by: -pain scale from 9/10 to 4/10 -Calm, relaxed and no longer irritable -Already able to smile.

- provide proper room ventilation.

-Cool
surroundings aid in minimizing dermal discomfort. -to promote lung expansion

o Facial grimace o Guarding behavior o Irritable o Teary eyes


VITAL SIGNS: BP: 130/80 T: 37.4 PR: 89 RR: 22

- Encourage use of relaxation technique like Deep breathing exercise

-encourage expressions of feeling contributing to pain

-to promote cooperation from the client

DATE: July 18, 2012

Assessment

Nursing Diagnosis Impaired tissue Integrity related to surgical incision.

Scientific Rationale

Planning

Nursing Intervention

Rationale

Evaluation

S= O= - Immobility

-subcostal kochers -Suturing technique Type of insicion Dry wet bleeding

VITAL SIGNS: BP: 130/80 T: 37.4 PR: 89 RR: 22

Impaired Tissue Integrity occurs when there is disruption of skin and tissues. Due to cholecystectomy, a surgical removal of the gallbladder it is done to remove gallstones or to remove an infected of inflamed gallbladder in order to relieve pain and infection.

After 3 hours of nursing intervention the patient will be able to participate willingly in activities that can promote healing and maintenance of skin integrity.

-Assist with general hygiene and comfort measures. later

Dry, intact, able to discuss ways how to clean the wound and maintain cleanliness and sterility. Expected evaluation.

1. Assess the area Sterile technique, povidine iodine 10%, wire gauze, Instruct the patient how to clean the incision by using sterile technique. Proper hygiene maintain the area dry 1st b4 bathing

-To promote comfort and a sense of well-being. -To avoid potential for infection. -To reduce the risk of spreading disease. -These measures reduce pressure, promote circulation and avoid skin breakdown. -To avoid skin injury. -To prevent the spreading of microorganisms. -To avoid skin injury. -To prevent the spreading of microorganisms. -To hasten wound healing and increase resistance.

After 3 hours of Pt was able to demonstrate and recite the proper steps in wound healing

-Change her position at least every 2 hours. -Monitor frequency of turning and skin condition.

DATE: July 18, 2012

-Remind patient not to scratch the area -Clean and dress the surgical incision site using the principles of sterility or medical asepsis. -Encourage patient to increase protein and vitamin C intake.

EVALUATION Assessment Nursing Diagnosis Scientific Explanation Objective Nursing Interventions Rationale The patient was able to participate in activities that will verbalize understanding of different intervention to reduce the risk for infection.

S=O O = The patient may manifest -increased wbc BP: 130/80 T: 37.4 PR: 89 RR: 22

Risk for infection related to post surgical procedure

DATE: July 18, 2012

Risk for infection means that the person has increased possibility of being invaded by pathogenic microorganism. It will cause decrease production of WBC leading to weak immune defenses. Broken skin or traumatized tissues or stasis of body fluids in the wound predisposes the person to invasion of pathogens coming from environment, thus increasing the risk for infection.

After 2 hours of nursing interventions, the patient will be able to participate in activities that will verbalize understanding of different intervention to reduce the risk for infection.

Intervention to impared skin integrity


- Establish rapport

-To gain patients trust and cooperation -To have baseline data on the treatment process -To note for etiology precipitating factors that causes risk for infection -To assess contributing factors and immediately provide the necessary intervention -To reduce existing risk factors

-Monitor and record vital signs -Assess patients condition -Note for signs and symptoms of sepsis ( fever, chills, diaphoresis and altered level of consciousness -Maintain sterile technique in cleansing the wound -Stress proper hand washing techniques by all caregivers between therapies -Encourage patient to increase protein and vitamin C intake

-To maintain aseptic technique

-To hasten wound healing and increase resistance

ASSESSMENT

NURSING DIAGNOSIS Knowledge deficit

PLANNING

NURSING INTERVENTION Avoid alcohol Proper exercise Assess patients level of anxiety.

RATIONALE

EVALUATION

Subjective: anung mangyayari skin kung patuloy akong iinum at kakain ng mataba Objective: Vital signs taken and recorded: BP: 130/80 T: 37.4 PR: 89 RR: 22

Short term: After 5 hours of nursing intervention patient will be able to reduce anxiety.

- To establish baseline data.

Short term:

Life style
- To help the patient have adequate period of rest and sleep. -To relax & provide comfort to the patient. Long term: Weigh loss

-Place patient in comfortable position. Long term: After two weeks of nursing care, patient will be able to accept changes in health - Provide nonstatus. pharmacological Therapies such as: T.V, Radio, Books, Socialization w/ others. - Provide calm activities.

- Can lessen the anxiety of the patient. -To give more information about his health status.

DATE: July 18, 2012

- Provide health teaching about cholecystitis

ASSESTMENT Subjective: Hindi ko alam Kung paano linisan yung sugat ko as verbalized by the patient.

DIAGNOSIS Knowledge deficient regarding condition and self care related to lack of information

PLANNING After 30 minutes to1 hour of nursing interventions the patient will verbalize understanding proper way of wound dressing

INTERVENTION - Demonstrate care of incisions or dressing or drains.

RATIONALE - Promotes independence in care and reduces risk of complications.

Objective: Request for information.

EVALUATION After 30 minutes to 1 hour of nursing intervention s the patient was able verbalize understandi ng proper way of wound dressing

V/S taken as follow: BP: 130/80 T: 37.4 PR: 89 RR: 22

DATE: July 18, 2012

DRUG NAME
Generic : CEFUROXIME Brand: Ceftin, Zinacef Classification:

ACTION
Bactericidal: Inhibits synthesis of bacterial cell wall causing cell death

INDICATION
Lower respiratory infections caused by S. pneumoniae, S. aureus, E. coli, Klebsiella pneumoniae UTIs caused by E. coli, Klebsiella pneumoniae Bone and joint infection due to S. aureus Perioperative prophylaxis

CONTRAINDICAT ION
Contraindicated with allergy to cephalosporins or penicillin Use cautiously with renal failure, lactation, pregnancy

ADVERSE EFFECTS
CNS: Headache, dizziness, lethargy, paresthesias GI: Nausea, , diarrhea, vomiting, pseudomembranous colitis GU: Nephrotoxicity Hematologic: Bone marrow depression( dec. WBC, dec. platelet,dec. Hct ) Hypersensitivity: Ranging from rash to fever to anaphylaxis Local: pain, abscess at injection site, phlebitis, inflammation at IV site Others: Superinfections, disulfiram-like reaction with alcohol

NSG. MANAGEMENT
Give oral drug with

-Antibiotic -Cephalosporin(2nd generation)


Frequency: every 8 hours Dosage: 750mg Route: IV

food to dec. GI upset and enhance absorption Have Vit. K available in case hypoprothrombinemi a occurs Discontinue if reaction occurs

DRUG NAME
Generic : Hyoscine N butylbromide Brand: Buscopan Classification:

ACTION
Inhibits muscarinic actions of acetylcholine autonomic effectors innervated by post ganglionic cholinergic neurons. May affect neural pathways originating in the inner ear on inhibits n/s.

INDICATION
Spastic state, delirium, pre anesthetic sedation and ascetic with amnesia with analgesics, to prevent n/v from motion sickness.

CONTRAINDICAT ION
Contraindicated in patient with angleclosure glaucoma, obstructive uropathy, obstructive disease of the GIT, asthma, chronic pulmonary disease Use cautiously in children younger than age 6.

ADVERSE EFFECTS
Disorientation, n/a, confusion, palpitation, tachycardia, dilated pupils, blurred vision, photophobia, n/v, urine retention, rash dryness, rash

NSG. MANAGEMENT
Raise side rails as a

Anti-Spasmodic
Frequency: now Dosage: 1 amp Route: IV

precautions because some patient temporarily excited or disorientation and some develop amnesia or become drowsy, reorient patient as needed. Tolerance may develop when therapy is prolonged.

DRUG NAME
Generic : Ketorolac Classification:

ACTION
Anti-inflammatory and analgesic activity, inhibits prostaglandins and leukotriene synthesis

INDICATION
Shortterm management of pain (up to 5 days) Ophthalmic: relief of ocular itching due to seasonal conjunctivitis and relief of postoperative inflammation after cataract surgery

CONTRAINDICATI ON
Contraindicated with significant renal impairment, during labor and delivery, lactation; patient wearing soft contact lenses (ophthalmic); aspirin allergy; concurrent use of NSAIDs; active peptic ulcer disease or GI bleeding; hypersensitivity to ketorolac; as prophylactic analgesic before major surgery; treatment of preoperative pain in CABG; suspected or confirmed cerebrovascular bleeding; hemorrhagic diathesis, incomplete homeostasis, high risk of bleeding use with probenecid, pentoxyphylline

ADVERSE EFFECTS
CNS: Headache, dizziness, somnolence, insomnia GI: Nausea, constipation, vomiting, abdominal pain, diarrhea GU: Gynecomastia, impotence or decrease libido Hemathologic: leucopenia, granulocytopenia, thrombocytopenia

NSG. MANAGEMENT
Take drug with

Antipyretic
Nonopioid-analgesic NSAID Frequency: every hours Dosage: 30mg Route: IV 8

meals and at bed time. Therapy may continue for 4-6 weeks or longer If you also are using an antacid, take it exactly as prescribed, being careful of the times of administration Have regular medical follow-up care to evaluate you response

DRUG NAME
Generic : Ranitidine Hydrochloride

ACTION

INDICATION
Short-term treatment of active duodenal ulcer Maintenance therapy for duodenal ulcer at reduce dosage

CONTRAINDICATI ON
Contraindicated with allergy to ranitidine, lactation Used cautiously with impaired renal or hepatic function, pregnancy

ADVERSE EFFECTS
CNS: Headache, dizziness, lethargy, paresthesias GI: Nausea, , diarrhea, vomiting, pseudomembranous colitis GU: Nephrotoxicity Hematologic: Bone marrow depression( decrease WBC, dec. platelet,dec. Hct ) Hypersensitivity: Ranging from rash to fever to anaphylaxis Local: pain, abscess at injection site, phlebitis, inflammation at IV site Others: Superinfections, disulfiram-like reaction with alcohol

NSG. MANAGEMENT
Give oral drug with

Competitively inhibits the action of histamine at the H2 receptors of the parietal cells of the stomach, inhibiting basal Brand: Zantac gastric acid secretion and gastric acid Classification: secretion that is Histamine 2 antagonist stimulated by food, histamine, Frequency: every 8 insulin cholinergic agonist, hours gastrin and pentagastrin Dosage: 1 amp Route: IV

food to dec. GI upset and enhance absorption Have Vit. K available in case hypoprothrombine mia occurs Discontinue if reaction occurs

DRUG NAME
Generic : metoclopramide Classification: Antiemetic Dopaminergic blocker GI stimulant Frequency: every 8 hours Dosage: 10mg Route: IV

ACTION
Stimulated motility of upper GI tract without stimulating gastric, biliary, or pancreatic secretion; appears to sensitize to action of acetylcholine; relaxes pyloric sphincter, which, when combined with effects on motility accelerates gastric empty and intestinal transmit; little effect on gallbladder or colon motility; increases lower esophageal sphincter pressure; has sedative properties; induces release of prolactin.

INDICATION
Parenteral: prevention of nausea and vomiting associated with emetogenic cancer chemotherapy Prophylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable

CONTRAINDICATI ON
Contraindicated with allergy to metoclopramide; GI hemorrhage; mechanical obstruction or perforation; pheochromocytoma; epilepsy

ADVERSE EFFECTS
CNS: restlessness, drowsiness, fatigue, lassitude, extra pyramidal reaction GI: Nausea, diarrhea

NSG. MANAGEMENT
Monitor BP

carefully during IV administration Monitor for extra pyramidal reaction, and consult physician if they occur

DRUG NAME
Generic : metronidazole Brand Name: Flagyl Classification: Amebicide Anti-bacterial Antibiotic Antiprotozoal Frequency: every 8 hours Dosage: 500mg Route: IV

ACTION
Bactericidal: inhibits DNA synthesis in specific anaerobes, causing cell death; antiprotozoaltrichomonacidal, amebicidal; biochemical mechanism of action is now known.

INDICATION
Acute infection with susceptible anaerobic bacteria Active intestinal amebiasis

CONTRAINDICATI ON
Contraindicated with allergy to metronidazole; pregnancy

ADVERSE EFFECTS
CNS: headache dizziness, ataxia, vertigo, insomnia fatigue GI: Nausea, diarrhea, unpleasant metallic taste, anorexia, GU: dysuria, incontinence, darkening of the urine

NSG. MANAGEMENT
Administer oral

doses with food


Take full course of

drug therapy; take the drug with food if GI upset occurs Your urine may be darker colored than the usual; this is expected Reduce dosage in hepatic disease .