Sie sind auf Seite 1von 6

ASSESSMEN

Subjective:
Sumasakit yung
tiyan ko banda
dito (points at the
RUQ of the
abdomen) akala
ko nung una wala
lang pero
hanggang ngayon
masakit parin.
Pain Scale: 8/10
Objective:

Facial mask
of pain
Tenderness
on right
upper
quadrant of
the abdomen
Guarding
behavior at
the RUQ
abdomen
Restless
Anxious
behavior
Tachycardia

NURSING
DIAGNOSIS

RATIONALE

Acute Pain related


to inflammation
and obstruction of
the gallbladder as
manifested by
report of RUQ
pain at the
abdomen

Cholelithiasis is
the formation of
gallstones, which
are composed of
cholesterol,
calcium salts, and
bile pigments.
When gallstones
block the flow of
bile, the
gallbladder
becomes swollen,
leading to the
possibility of pain
and inflammation.

PLANNING

Short term goal;


After 2 hours of
nursing
interventions, the
patient will be
able to:

Understand
the reason
behind the
pain
Demonstrate
effective
relaxation
techniques
Control
reported pain
Minimize pain
by 2-4/ 10
pain scale
from 8/10

Long term goal:


After 3 days of
nursing
interventions, the
patient will be
relieved of any
pain or

NURSING
INTERVENTI
ONS

RATIONALE

Independent:
1.

Monitor
location,
severity and
character of
pain.

Monitor serves as
a baseline date to
monitor progress
of complication
and effectiveness
of intervention.

2.

Promote bed
rest. Assume
position of
comfort or
advice at
low fowler
position.

Bed rest in low


fowler position
reduces intraabdominal
pressure.

3.

4.

Control
environment
al
temperature
.
Encourage
use of
relaxation
techniques
(guided
imagery,
deep
breathing

Cool surroundings
aid in minimizing
discomfort.
Promotes rest,
redirect attention
and enhance
coping

EVALUATIO
N

After 2 hours of
nursing
interventions, the
patient was able
to understand the
disease process of
cholelithiasis,
demonstrates
effective
relaxation
techniques,
controls pain and
minimize pain by
4/10.
After 3 days of
nursing
interventions, the
patient was
relieved of any
pain or
discomfort.

discomfort.

Tachypnea

exercise,
diversional
activities)
5.

Make time to
listen and
maintain
frequent
contact with
patient.

Helpful in
alleviating
anxiety and
refocusing
attention, which
can relieve pain

Dependent:
1.

ASSESSMEN
T

NURSING
DIAGNOSIS

RATIONALE

PLANNING

Maintain on
NPO status
as per
physicians
order.

NURSING
INTERVENTI
ONS

Prevents gastric
secretions that
stimulates release
of cholecystokinin
and gallbladder
contraction.

RATIONALE

EVALUATIO
N

Subjective:
Nahihirapan lang
ako gumalaw
galaw dahil
sariwa pa yung
sugat. Masakit pa
tsaka baka
bumuka.
Pain scale: 3/10
Objective:

Surgical
incisions on
the
abdomen
Guarding
behavior
Limited
body
movement
Anxiety
Restlessnes
s

Impaired physical
mobility r/t
presence of
surgical incision
AEB slowed,
limited
movement, report
of discomfort and
pain on suture
sites upon
movement
secondary to post
cholecystectomy

Presence of
surgical incision
procedures
causes the
patient to be
reluctant in doing
movements such
as ROM, because
those may result
in the stimulation
of the nerve
endings, during
movement, thus,
increase pain
sensation.

Short term goal:


After 1 hour of
appropriate
nursing
interventions, the
patient will be
able to identify
measures to
move freely and
safely without
experiencing any
discomforts

Independent:
1.

Monitor
location,
severity and
character of
pain.

Monitor serves as
a baseline date to
monitor progress
of complication
and effectiveness
of intervention.

2.

Assist
patient on
repositioning
every 2
hours.

It will keep blood


flowing to their
skin. This helps
their skin stay
healthy and
prevents
bedsores. It will
increase the
patients mobility
as well.

3.

Star t
minimal
ROM
exercises as
tolerated by
the patient.

Long term goal:


After 6 hours of
appropriate
nursing
interventions, the
patient will be
able to
demonstrate
resumption of
activities.

It will help the


patient in gradual
resumption of
activities.

4.

Support
surgical sites
with pillow
when
moving.

The pillow will


serve as the
cushion of the site
to prevent it from
contracting and
receiving
pressures causing
pain.

5.

Provide
adequate
rest periods.

Rest periods will


help the patient

After 1 hour of
appropriate
nursing
interventions, the
patient was able
to identify
measures to
improve mobility
After 6 hours, the
patient
demonstrated
improved physical
mobility.

6.

Encouraged
independent
movements
as tolerated
by the
patient.

Dependent:
1. Administer
analgesic
medications
as ordered
by the
physician

ASSESSMEN
T

NURSING
DIAGNOSIS

RATIONALE

PLANNING

NURSING
INTERVENTI

save energy for


the next
scheduled
exercise
Promoting patient
independency will
increase the self
esteem of the
patient and
avoiding
dependent
behavior.
To promote free
pain relief.

RATIONALE

EVALUATIO
N

ONS
Subjective:
N/A
Objective:

Several
surgical
incision on
the abdomen
First
operation
of the
patient

Risk for infection


r/t post-operative
incision
secondary to
cholecystectomy

The patient is at
risk of acquiring
infection due to
the break in the
continuity of the
first line defense
which is the skin.
The patient have
undergone
cholecystectomy
thus there is an
incisions and
sutures made in
the abdomen.
Once there is a
breakage in the
skin, the patient
is at an increased
risk on getting
infected since
pathogens have
an easier access
to invade the
body.

Short term goal:

Independent:

After 1 hour of
nursing
interventions, the
patient will be
able to:

1.

Monitor vital
signs and
assess
patients
condition

This will serve as


a baseline date
for further
comparison.

2.

Teach the
patient
about
infection.

Understanding
infection will help
the patient be
aware of any
signs and
symptoms. It will
help the patient
to prevent the
infection as well.

Gain
knowledge
regarding
infection
control
Demonstrate
techniques in
reducing risks
of having an
infection

3.

Stress
proper hand
washing
techniques

Long term goal:


After 2 days of
nursing
interventions,
the patient will
achieve time
wound healing
and free of any
infections.

4.

5.

Teach the
proper way
of applying
wound
healing.

Increase oral
fluid intake

Correct hand
washing is the
first line of
defense against
nosocomial or
cross
contamination.
Performing the
proper way in
wound dressing
will prevent
pathogens
entering the
incisions thus
prevent infection.
Increased oral

After 1 hour of
nursing
intervention, the
patient was able
to gain and
understand
infection control
and was able to
demonstrate
measure to
prevent infection.
After 2 days of
nursing
interventions, the
patient was able
to achieve timely
wound healing
and was free of
any signs of
infections.

Dependent:
1.

2.

Stress
medication
compliance
to antibiotics
as
prescribed
by the
physician
Monitor
medication
regimen.

fluid in the body


will help hasten
the healing
process.

The antibiotic will


prevent the
occurrence of
infection.

Monitoring the
intake of drugs
will determine the
degree of
effectiveness of
the therapy.