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
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
Understand
the reason
behind the
pain
Demonstrate
effective
relaxation
techniques
Control
reported pain
Minimize pain
by 2-4/ 10
pain scale
from 8/10
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.
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.
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.
3.
Star t
minimal
ROM
exercises as
tolerated by
the patient.
4.
Support
surgical sites
with pillow
when
moving.
5.
Provide
adequate
rest periods.
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
RATIONALE
EVALUATIO
N
ONS
Subjective:
N/A
Objective:
Several
surgical
incision on
the abdomen
First
operation
of the
patient
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.
Independent:
After 1 hour of
nursing
interventions, the
patient will be
able to:
1.
Monitor vital
signs and
assess
patients
condition
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
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.
Monitoring the
intake of drugs
will determine the
degree of
effectiveness of
the therapy.