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#1 Activity intolerance r/t limited range of activity 2o cholecystectomy (Postoperative)

Assessment Diagnosis Planning Interventions Rationale Evaluation

S> “I can’t Activity Short term: > monitor > to obtain baseline data Short term:
do simple intolerance Vital signs
things by r/t limited After 4 hrs of > assess > adequate proteins/ The patient shall
myself”, as range of NI, the pt. nutritional calories are needed for have maintained
verbalized by activity 2o s/p will be able status wound healing after functional
the patient. cholecystecto to maintain Cholecystectomy alignment of all
my functional > assess pt’s extremities and
O> the alignment of level of > aids in defining what avoid
patient may all mobility patient is capable of contractures
manifest: extremities without compromising the
and avoid health and wellness of
> Fatigue contractures the patient after Long term:
cholecystectomy which is
> Weakness necessary before setting The patient shall
Long term: realistic goals have verbalized
> Inability in > refrain understanding on
performing After 3 days from > patient with limited health teachings
ADLs without of NI, the pt. performing activity tolerance need to about risk factors
assistance will be able non-essential prioritize tasks in order and individual
to verbalize procedures not to compromise health treatment
>with clean understandin and to prevent regimen and
and dry g on health complications such as safety measures
wound teachings evisceration
dressing over about risk
RUQ factors and > monitor
individual patient’s > difficulties sleeping
>abnormal treatment sleep pattern need to be addressed
HR or BP regimen and and amount before activity
safety of sleep progression can be
>Pallor measures achieved achieved
over past few
>Dyspnea days

>Exertional > involve pt.


Discomfort and health > setting small attainable
care goals can increase
>Dysrhytmia professionals confidence and self-
s or ischemia who handle esteem of the patient
>cyanosis the patient in after the procedure
goal setting
and care
planning

> teach > to reduce oxygen


about energy consumption
consumption

> teach > to conserve energy and


appropriate prevent injury from fall
use of which may further
environment aggravate the client’s
al aids condition
> encourage
pt. to > reduce feelings of fear
verbalize and anxiety
concerns
about
discharge
and home
environment
> helps to minimize
>acknowledg frustration, rechannel
e difficulty of energy
the situation > to develop individually
for the client appropriate therapeutic
regimens

> provide > to establish individual


referral to goals for faster recovery
other
disciplines as
indicated
> to prevent injuries and
> review complications that may
expectations develop that could
of client aggravate the patient’s
condition
> assist > to sustain motivation
client to learn
appropriate
safety
measures
#2 Hyperthermia (Postoperative)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

O> The Hyperther Short Term: > Assess >to obtain Short Term:
patient may mia underlying comparative
manifest: After 4 hours of condition and body baseline data and to The patient‘s
NI, the patient temperature assess contributing temp. shall have
>increase of temp. will factors. decreased from
temperature decrease from 38.5°C to 37.5°C
above normal 38.5°C to >Monitor and >to note for
(38.5°C 37.5°C recorded vital progress and
approx.) signs especially evaluate effects of Long Term:
Long Term: temperature hyperthermia
>skin is warm The patient shall
to touch After 2 days of >Assess >To evaluate effects have maintained
NI, the patient neurologic or degree of core
>with flushed will maintain response, noting hyperthermia temperature
skin core level of within normal
temperature consciousness and range.
>increase within normal orientation,
respiratory range. reaction to stimuli
rate and presence of
posturing or >to assist with
>unstable BP seizures measures to reduce
>seizures and body temperature or
convulsions >Remove restore normal body
>confusion unnecessary or organ function
clothing that could
only aggravate
heat >it supports
circulating volume
and tissue perfusion

>reduces metabolic
>Encourage demands or oxygen
increase fluid
intake if not
contraindicated >to promote surface
cooling
>Promote
adequate rest >To meet metabolic
periods demands

>Provide TSB >Antipyretics lowers


core temperature

>Advise high
calorie diet

>Administer
antipyretics as
ordered
#3 Acute pain (Preoperative)

ASSESSMENT
DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

S> “masakit ang Acute Pain Short Term: >Establish rapport >to gain patient’s trust Short Term:
tahis s tiyan ko”, secondary
as verbalized by to After 4 hours >Assess patient >to be specific of the After 4 hours
the patient. cholecyste of NI, the quality onset, kind of pain of NI, the
ctomy patient will duration, location experienced patient shall
O> The patient be able to and intensity of pain. have
may manifest: verbalize a >Monitor and record >to obtain baseline verbalized a
>guarding decrease in vital signs. data decrease in
behavior on RUQ pain. >Provide comfort pain.
portion of the measure such as >to promote rest and
stomach Long Term: quite environment enhance the effects of
>nausea and using relaxation analgesics given Long Term:
vomiting After 2 days techniques, backrub,
>facial grimace of NI, the comfortable After 2 days
>unable to move patient will positioning >to assist patient and of NI, the
freely be able to >Provide individuals family to respond patient shall
> self focusing verbalize with opportunities to optimally to the have
>abdominal relief of discuss fear and individual’s pain verbalized
heaviness pain. acknowledge the experience relief of pain.
>narrowed focus difficulty of situation.
>expressive >Provide divertional >to divert focus of the
favor activities pt. to the pain.
>sleep
disturbance >Administer pain >to decrease or totally
medication as diminish pain.
ordered.
#4 Imbalanced Nutrition: less than body requirements
CUES NURSING SCIENTIFIC PLANNING NURSING RATIONA EXPECTED
DIAGNOSI EXPLANATIO INTERVENTI LE OUTCOMES
S N ONS

S= 0 Risk for Short term: >Instruct >for easy Short term:


Imbalanced After surgery, After 4 patient to eat digestion After 4
O= the patient Nutrition: the body hours of NI, soft foods or and hours of NI,
needs extra
may manifested less than the pt will if solid foods, prevention the pt. shall
calories and
the ff: body protein for demonstrat should be of reflux. have
o restlessness requiremen wound healing e increased eaten in small demonstrat
o nausea and ts r/t and recovery. appetite. frequent ed
vomitting surgery At this time, feedings. increased
o pain in the many people >to alter appetite.
incision site. have some >Provide feeling of
pain scale of pain and
7/10 diversional nausea
fatigue. In
o body malaise addition, they activities and
o difficulty in may be Long term: when there is prevent
moving and unable to eat After 1-3 feeling of vomiting. Long term:
positioning a normal diet days of NI, nausea or After 1-3
o sleeplessness because of the pt will urge to vomit days of NI,
o loss of surgery- report >to the pt shall
appetite related side
absence of >Restrict prevent manifest
effects. The
body's ability nausea and foods which indigestion relief of
to use vomiting, rich in fats. . body
nutrients may decreased weakness
also be pain >Encouraged and be able
changed by sensation, pt. to position >to to promote
the removal of
increased self to high decrease wound
gall bladder.
appetite fowlers when occurrence healing and
and be able eating. of pain in prevent risk
to relieve the site of for
body >Instruct to surgery. imbalanced
weakness eat foods rich >to nutrition.
and regain in vit. C. promote
strength.. timely
>Advised to wound
eat food rich healing
in
#5 Disturbed sleep pattern

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

S= “I cant fall Disturbed Short term: >Instruct pt to perform >To ease pain felt Short term:
asleep easily sleep After 2-3 deep breathing After 2-3
especially at pattern r/t hours of NI, exercises hours of NI,
night”, as series of the pt will >To promote the pt. have
verbalized by acute pain demonstrate >Provide comfort feeling of comfort obtained a
the patient. in the site decreased measures such s and prevent nap of 3-4
of surgery. pain stretching of bed linens uneasiness hours
O= the patient sensation and changing of soiled
may manifested and will be clothing
the ff: able to >To promote
o Pain in the promote >Provide a cool and relaxation
site of sleep for 3-4 quiet environment conducive for
incision hours. sleeping Long term:
(pain >Promote proper After 1-2
scale:
Long term: hygiene or wound >To promote faster days of NI,
7/10)
o Irritability After 1-2 cleaning. wound healing the pt
o Sleepless days of NI, manifested
nights the pt will >Perform visual >To relieve feeling sleeping
o Facial manifest imagery of pain. hours of 6-8
grimaces improvemen hours every
t of >To lessen night.
rest/sleep >Administer analgesics occurrence of pain
pattern. as prescribed
#6 Risk for infection r/t presence of surgical incision secondary to cholecystectomy
(Postoperative)

ASSESSME DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION


NT

O> patientRisk for Short Term: >Assess >to obtain comparative Short Term:
may infection r/t underlying baseline data
manifest: presence of After 4 hours of condition and body The patient
surgical NI, the patient temperature shall have
>febrile incision 2o s/p will be able to >to assess verbalized
cholecystecto verbalize >Observe for causative/contributing understanding
>weakness my understanding localized signs of factors of health
of health infection on the teachings
>with teachings incision site. provided to
dizziness provided to > to note for progress prevent spread
prevent spread >Monitor and and evaluate for risk of of infection.
>Increase of infection. recorded vital infection
in WBC signs
>it supports circulating Long term:
>open >Encourage volume and tissue
wound Long Term: increase fluid perfusion and it aids in The patient
intake if not the elimination of shall have
>inadequa After 2 days of contraindicated microorganisms that exhibit
te acquired NI, the pt. will may contribute to the decrease risk of
immunity be able to occurrence of infection spread of
exhibit infection.
>malnutriti decrease risk >reduces metabolic
on for spread of >Promote demands or oxygen
infection adequate rest
periods >decreases the risk for
infection.
>Encourage
proper hygiene >to prevent infection

>Perform aseptic
technique >to decrease risk for
infection since prolong
>Encourage early immobilization can
ambulation contribute to the
accumulation of
secretions and may lead
to infection.

>Administer >prophylaxis to prevent


antibiotics as infection
ordered