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American University of Beirut School of Nursing

NURS 302- Nursing Care of Adults II Practicum

Nursing Care Plan Form

Student: ___Hoda hayek________________ Date: ___30/4/2020______________

Unit: ____

First Priority Nursing Diagnosis

_Acute pain _____________________ related to ___surgical incision
________________________ secondary to _cholecystectomy ___________________
evidenced by patient complains of pain

Expected Outcomes
1. Patient is expected to verbalize that the intensity of pain is decreased
Nursing Management

Assessment
1 Assess pain using COLDSPA
2 Monitor vital signs
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Therapy
1 Provide analgesic
medications depending on
the severity of pain
2 Encourage the patient to
use non-pharmacological
methods (breathing
technique, relaxation
exercise )
3 Provide rest periods and
decrease stress
4 Clean the site of incision
and drainage
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6
Rationale
Assessment is important in order know how to manage
pain and to adequate strategies
High BP and pulses may be present with pain and shows
the intensity of pain
Rationale
It decreases pain by reduce the production of
prostaglandin in the brain and spinal cord
These methods are used to alter thoughts and focus
concentration to manage pain and they will also enhance
the effects of analgesics
Stress and fatigue increase pain so quiet environment is
important in managing pain
Keeping the site of incision clean will decrease the chance
of infection and will decrease pain

Patient/ Family Education
1 Teach the patient not to do
physical activities
2 Teach the patient to report
pain to the nurse
immediately
2
Rationale
Heavy lifting and exercise will put pressure on the
incision and causes pain
This will let the nurse to do the appropriate interventions
quickly and to facilitate the care plan to prevent
complications and to reduce pain
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Second Priority Nursing Diagnosis

___ Excess fluid volume___________________ related to
___ascites________________________ secondary to __liver dysfunction__________________
evidenced by high AST (98U/L) and ALT (189U/L)

Expected Outcomes
Patient is expected to have normal liver function test and balanced intake/output

Nursing Management

Assessment
1 Assess the abdominal girth
2 Monitor urine
intake/output
3 Monitor weight daily
Therapy
1 Restrict sodium intake
2 place the patient in a semi-
fowler position
3 Provide potassium sparing
diuretics (aldactone)
4 Positioning every 2 hours
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Patient/ Family Education
1 Educate the patient about
the importance of diet and
restricted sodium
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Rationale
It reveals if the fluid in the abdomen increase or decrease
Patient may develop dehydration because of the shifting
of fluid even if the overall fluid intake is normal
It shows the accumulation of fluid and monitor any
change in ascites formation
Rationale
sodium increases fluid retention
It provides comfort in breathing
It removes the excess body fluids and maintains
electrolyte balance
It prevents accumulation of fluids in the extremities
Rationale
It provides the patient knowledge about her disease and
how to treat ascites