ncp cholehgxk

7/27/2019 NCP Cholehgxk

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NURSING CARE PLAN

1. Acute pain related to presence of surgical incision secondary to status post laparoscopic

cholecystectomy.

2. Impaired skin integrity related to surgical procedure: laparoscopic cholecystectomy secondary to

calculous cholecystitis

3. Risk for infection related to presence of surgical incision.


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NURSING CARE PLAN

1. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy.

Assessment Nursing Diagnosis Planning Nursing Interventions EvaluationSubjective:

Masaki ang opera ko

as verbalized by the

patient

Objective:

pain scale of 8 out of

10

facial grimaced

Guarding behavior at

the incision sites

Slow and limited

movement of the

upper extremities

0.5 mm incision on the

right lower rib cage

and the subxyphoid

Acute pain related to

presence of surgical

incision secondary to

status post laparoscopic

cholecystectomy as

evidenced by pain scale

of 8/10.

( Pain is a common

aftermath for every

surgery after the

anesthesia wore down.

Pain is recognized in two

different forms:

physiologic pain and

clinical pain. Physiologic

pain comes and goes,

and is the result of

experiencing a high-

At the end of 3

hours nursing

intervention,

the patient will

be able to

report a

decrease in

pain intensity to

a scale of 3 out

of 10.

> Monitor and assess vital signs every

2 hours becausevital signs are usually

altered in acute pain

>Instruct and demonstrate to the

patient the use of deep breathing

exercise. Also instruct patient to do

splinting while doing deep breathing

exercises.Deep breathing increases

oxygen in the body and prevents

atelectasis. Deep breathing exercise

also provides comfort.Splinting while

doing deep breathing is to lessen the

pain upon respiration.

>Position the patient properly in bed.

Elevate head of bed. Maintain

anatomic alignment.Alignment helps

prevent pain from malposition and it

enhances comfort

At the end of

rendering 3

hours nursing

intervention, the

patient was

able to report

pain as relieved

and controlled.


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area; 10mm incision

below the umbilicus.

Incisions are covered

with dry and intact

dressing.

Vital Signs: T- 36.6C;

BP- 130/90; RR-18;

PR- 81.

intensity sensation. It

often acts as a safety

mechanism to warn

individuals of danger

(e.g., a burn, animal

scratch, or broken glass).

Clinical pain, in contrast,

is marked by

hypersensitivity to painful

stimuli around a localized

site, and also is felt in

non-injured areas nearby.

When a patient

undergoes surgery,

tissues and nerve

endings are traumatized,

resulting in incision pain.

This trauma overloads

the pain receptors that

send messages to the

spinal cord, which

becomes overstimulated.

The resultant central

>Encourage diversional activities

(TV/radio, socialization with others,

mental imaging).These highten ones

concentration upon nonpainful stimuli to

decrease one's awareness and experience

of pain.

>Provide rest periods to facilitate

comfort, sleep, and relaxation.The

patient's experiences of pain may

become exaggerated as the result of

fatigue. Adequate rest helps provide

comfort

>Assist patient in doing her activities of

daily living.Helps reduce pain brought

about by the exertion of force

necessary to perform activities

>Encourage patient to report pain as

soon as it starts and allow her to

verbalize pain experienced or describe

the pain shes feeling.Severe pain is

more difficult to control and increases

the clients anxiety and fatigue.


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sensitization is a type of

posttraumatic stress to

the spinal cord, which

interprets any

stimulationpainful or

otherwiseas

unpleasant. That is why a

patient may feel pain in

movement or physical

touch in locations far from

the surgical site)

>Administer analgesics as ordered by

attending physician


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Assessment Diagnosis Planning Nursing Interventions Evaluation

Subjective:

inoperahan ako sa

tiyan gawa nga nang

may bato sabi ng

doktor, as verbalized

by the patient

Objective:

>post laparoscopiccholecystectomy

>disruption of the

dermis, epidermis, and

subcutaneous tissues.

>with 0.5 to 1 cm

incisions at the

epigastrium, right lower

rib cage and below theumbilicus

->ncisions covered with

dry and intact dressing

>skin slightly warm to

touch. Temperature:

Impaired skin integrity

related to laparoscopic

cholecystectomy surgerysecondary to calculous

cholecystitis.

(Laparoscopic

cholecystectomy is a less

invasive way to remove

the bladder. It is

performed through

inserting a laparoscope

just below the navel.

Three additional ports are

inserted by making three

other incisions in the

epigastrium and in the

right upper quadrant of

the abdomen)

At the end of 8

hours of

nursingintervention the

patient will be

able to display

improvement in

wound healing

>monitor vital signs especially

temperature every 4 hours. Early

recognition of developing infectionenables rapid institution of treatment

and prevention of further

complications.

>Assess dressings/ wound everyday.

Describe wounds and observe for

changes. this Establishes comparative

baseline providing opportunity for

timely intervention.

>Keep the incision site clean and dry,

carefully dress wounds. Keeping

incision site clean and dry prevents

infection; it also aids in the process of

wound healing.

>Encourage early ambulation. Assist

patient in doing active and passive

range of motion exercises. Movement

stimulates circulation and assists in the

bodys natural process of repair.

>Place in semi-Fowlers position or

moderate high back rest. Proper

At the end of 2

days nursing

intervention, thepatient was able

maintain

incision site and

dressing intact

and dry.


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36.6C positioning decreases tension in the

operative site and promotes healing.

>Instruct to wear clean, dry, loose-

fitting clothes, preferably cotton fabric.

Skin friction caused by stiff or rough

clothes leads to irritation of fragile skin

and increases risk for infection. Loose

clothing reduces pressure on

compromised tissues, which may

improve circulation/healing

> Emphasize importance of adequate

nutrition and fluid intake. Encourage

patient to eat foods rich in protein, iron

and vit. C. Improved nutrition and

hydration will improve skin condition.

Protein and iron helps in repair of

tissues. Vitamin C is important for

immune system function and increases

resistance to some pathogens.

>Administer antibiotics as indicated.

May be given prophylactically or to

treat specific infection and enhance

healing.


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Subjective:

Patulong naman akong

umupo, nahihirapan

akong huminga as

verbalized by the

patient

Objective:

>nasal flaring

>use of accessory

muscles to breath

>RR:

Ineffective breathing

pattern related to incision

as evidenced byverbalization of the

patient.

After one hour

of nursing

intervention,the patient will

be able to

breathe without

difficulty

>monitor vital signs especially

respirator rate

>encourage to have deep breathing

exercise with rolled towel pressure on

incision site.

>encourage patient to position on

comfort

>keep the patient dressing dry

>drain foley catheter to urinary bagfrequently

>advise patient to avoid overeating

gas-forming foods that may cause

abdominal distention

>give analgesic as prescribed by the

physician to promote deeper

respiration

After one hour

of nursing

intervention, thepatient was able

to breathe with

ease.


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S Dok, nagnanana

oh!, as verbalized by

the patient

O

-T: 38C

- WBC of 14.1

_ pain on the incision

sites (8/10)

-(+)pus

-redness on the incision

site

-with foley catheter

Risk for infection related

to laparoscopic

cholecystectomy surgery

After 8 hours of

nursing

intervention,the patients

risk of infection

will be lessen

>monitor vital signs. Any alteration in

temperature and blood pressure

indicates infection invasion.

>keep the patient dressing dry to

prevent accumulation of microbes

(especially when soaked in blood).

>drain foley catheter to urinary bag

frequently to lessen risk of

multiplication of bacteria. Foley

catheter opens the urinary system to

pathogens.

Teach patient and relatives of proper

hand hygiene to prevent further

transfer of infection.

>encourage the patient to increase

fluid intake to promote hydration of

client.

> Use aseptic technique to lessen therisk in cleaning the wound and drainingthe catheter>Use hand sanitizers with alcoholbased and have handwashing beforehaving any contact to the client

After 8 hours of

nursing

intervention, thepatients risk

decreased.


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