NURSING CARE PLAN Patients Name: JFY Age : 38YRS OLD Diagnosis :CHRONIC CALCULUS CHOLECYSTITIS AND RETENTION

CYSTITIS Hospital No: 060022346101 Room No. : B639 Physician : DR. RAMA

CLINICAL PORTRAIT Seen patient lying on bed with head slightly elevated, awake conscious, coherent, responsive, ongoing IVF of # 7 PNSS 1L @130 cc/hr with 300cc level remaining infusing well at patients right arm, afebrile, side rails up on both sides. Grimaced face, destended bladder noted, complaining pain at the hypogastric area.incission site noted at the left hypochondriac area, 2-3 inches in length. Vital signs taken as follows T: 36.7C PR: 91bpm RR: 22cpm BP: 130/90mmHg Identified Nursing Problems

PERTINENT DATA A case of patient JFY 38 years old single from Lapu-lapu City was admitted to Chong Hua Hospital on September 20, 2011 due low back pain, weakness and numbness on both lower extremities particularly on the left foot. The patient was admitted in the year 2006 due to Lumbar Stenosis at Chong Hua Hospital. The symptoms of low back pain, weakness and numbness were the symptoms of her condition that time. In following year, 2007 she was confined at Perpetual Soccour. Hospital because of Lumbar Irritation Radiculopathy. In that condition the nerves of her lumbar spine was irritated by disease any where along their paths--from their roots at the spinal cord to the skin surface. Her symptoms at that time were the pain which commonly increases with movements at the waist and can increase with coughing or sneezing. In the year 2008-2010 where she was admitted at Chong Hua Hospital because of her Lumbar conditions and lumbar biopsy was done. Recently this year 2011, she was again admitted at Chong Hua Hospital due to Lumbar Ridiculopathy and was rulled out with cholecystitis. Still good because it was successfully treated by a surgery of cholecystectomy. 2005 patient stable feeling numbness in both extremities associated with weakness. There was pain in lower area, no problem with ADL's. At first part,

1. Alteration in comfort: Chronic pain 2. Activity intolerance related to fatigue 3. Impaired skin integrity related to surgical incision 4. Sleep pattern disturbance related to environmental factors

5. Risk for infection

tolerated condition. Currently she sought consult with gemologist. Laboratory done. Pain medication given. Claimed there was just mild relief. Refer to rehab specialist and underwent physical therapy.

Weeks PTA, patient mention numbness with electric sensation in both lower extremities, more noted on left lower extremity. She had some difficulty in walking as electric sensation was continuous without any relief and persistent. Sought consult with her rehab MD and referred to present admitting physicians. Advised admission. Vital Signs Taken During Admission T-36.5C P-82bpm R- 18cpm BP-130/90mmhg

CUES

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS & OUTCOMES CRITERIA

NURSING ACTIONS & NURSINGORDERS

RATIONALE OF NUIRSING ORDERS

EVALUATION

Subjective cues kapoy pako day ganahan rako tolog permi as verbalized by the patient Objective cues  lying flat on bed with head slightly elevated  with on going IVF of # 7 PNSS 1L @130 cc/hr with 300cc level remaining infusing well at patients right arm  conscious  coherent  limited range of motion noted  afebrile  with the

Activity intolerance related to fatigue secondary to surgery.

Fatigue is common after major surgery and delays recovery. it is usually attributed to the physiological response to surgery. The physiological response to surgery was determined by sequential measurements of circulating norepinephrine, epinephrine, cortisol, interleukin-6, and C he main predictor of worse physical well being at 3 days was the size of the Creactive protein response. Subsequently, the main predictor was the level of preoperative well being. The severity of fatigue and vigor after surgery were predicted mostly by the preoperative levels of the respective variable.reactive protein. Christensen T, Kehlet H. Postoperative fatigue. World J Surg 20063; 2015:

After 8 hours of Independent patient- nurse interaction the patient 1.Establish Rapport and the family will be able to: 2. Monitor and record 1. acquire vital signs knowledge about the disease condition 3.Instruct the SO not to leave the patient 2. identify unattended factors that reduce 4. Provide client with a activity positive atmosphere intolerance

Goal was meet To obtain baseline data 1.Patient verbalizes factors that reduce activity To note for any unusualities intolerance like having rest periods in every activities 2.) patient was able to perform daily activity like going to the toilet . 3.) patient verbalized of feeling better .

to prevent injuries to help minimize frustration and to gain energy

3. maintain

activity level
4. perform daily

5.Encourage patient to have adequate bed rest and sleep Dependent 1. Administer medication per doctors order Collaborative:

to provide relaxation and to decreases oxygen consumption

activities alone

to relieve the discomfort and for the treatment of the disease

following vital signs T: 36.7C PR: 91bpm RR: 22cpm BP: 130/90mmHg

2205. 1. facilitate laboratory exam per doctors order 2.Collaborate to the dietitians to determine or to diagnose the causes of the disease to assess nutritional needs . Dietitians can recommend dietary changes that can improve the client's health status to prevent further complications

3.report any unusualities

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Cues/Evidences Nursing Diagnosis Subjective data: dili mn kayo dako ang gisi nga giagian sa opera day, sakitsakit pd siya gamay nya matandugan pud ni siya usahay. Gitauran pud ko nila ug catheter as verbalized by the patient. Risk for infection related to post open cholecystectomy

Scientific Basis

Goals and Outcome Criteria Goal: After 8 hours of nursepatient interaction the client will remain free of infection.

Nursing Actions and Nursing Orders Nursing Strategy: After 8 hours of nursing intervention; the nurse will be able to help client in maintaining infection free.

Rationale

Evaluation

Objective data: y y y y Patient is seen awake Restless With Foley catheter From post open cholecystect

Colelithiasis, calculi, or gallstones, usually from the gallbladder from the solid constituents of bile; they vary greatly in size, shape and composition. They are uncommon in children and young adults but become more prevalent with increasing age, affecting 30% to 40% of people by the age of 80 years old. (Brunner & Suddarth, 12th edition, page 1172) Laparoscopic Cholecystectomy has dramatically changed the approach to the management of cholecystitis. It has become the new

Outcome Criteria: Specifically the patient will be able to: 1. Remain free from symptoms of infection. Independent:  Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature

Goal met.  Patient and S.O. was able to demonstrate proper hand washing.  Temperature remains normal.  Eat the prescribed diet.  Medications prescribed were taken on time.

 With the onset of infection the immune system is activated and signs of infection appear. 

 Assess patients temperature every

omy

standard for therapy of symptomatic gallstones. Before, the procedure, the patient is informed that an open abdominal procedure may be necessary and general anesthesia is administered. Laparoscopic cholecystectomy is performed through a small incision or puncture made through the abdominal wall at the umbilicus. The abdominal cavity is insufflated with carbon dioxide to assist in inserting the laparoscope and to aid in visualizing 2. Eat the prescribed diet. the abdominal structures. (Brunner & Suddarth, 12th edition, page 1177)

4 hours

 Temperature of greater than 37.5 degree Celsius is an indicative of infection

 Assess skin for color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of changes.  Drain/ empty patients urine every end of shift with the use of clean gloves.

 Intact skin is nature's first line of defense against microorganisms entering the body

 To monitor patients urine output and to prevent onset of infection.

 Encourage a balanced diet, emphasizing proteins to feed the immune system

 Immune function is affected by protein intake (especially arginine); the balance between omega-6 and

omega-3 fatty acid intake; and adequate amounts of vitamins A, C, and E and the minerals zinc and iron. A deficiency of these nutrients puts the client at an increased risk of infection. Collaborative:  Teach/ educate client and S.O. the signs and symptoms of infection

 Provides collaboration and teamwork between patient and health provider.

2. State symptoms of infection of which to be aware.

 Teach and demonstrate with the patient on how to do proper handwashing.

 Provides knowledge to the patient.

4.Demonstrate

 Instruct patient on how to properly

appropriate hygienic measures such as hand washing

and carefully do wound care.

 Provides independence to the patient in caring for her wound.

Dependent: 5.Demonstrate appropriate care of infection-prone site  Administer medication as prescribed by the doctor.

 To remain patient free from infection.

6. Take medication for infection control.

CUES

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS & OUTCOME CRITERIA

NURSING ACTION & NURSING ORDERS

RATIONALE OF NURSING ORDERS

EVALUATION

SUBJECTIVE: di kayo ko katulog kay daghan ug bisita, as verbalized by the patient.

Sleep pattern disturbance related to environmental factors

OBJECTIVE: With the ff. v/s: T: 36.7 C PR: 91bpm RR: 22cpm BP: 130/90m mHg With ongoing IVF of # 7 PNSS 1L

Environmental noise and sleep disturbances go hand in hand. Environmental noise can deeply impact sleep in a negative way, leading to terrible sleep disturbances that can harm ones health and ones quality of life(Doenges, Mur,7th edtion NCP;957).

After 8 hours of varied INDEPENDENT nursing intervention. The patient will be able to enhance physical 1.)Assess for sleeping mobility. patterns( Doenges et al., 7th edition NCP, 345) Specifically the client will: Verbalized understanding of sleep disturbances Identify individually appropriate interventions to promote sleep Report improvement in sleep/rest pattern

After 8 hours of varied nursing interventions the goal was met. Client was 1.)As basis or acts as the able to: baseline data for the next observations to follow. ( Doenges et al., 7th edition - Verbalized that her NCP, 345) sleeping patterns were improved.

2.)Restrict intake of caffeine containing foods/fluids ( Doenges et al., 7th edition NCP, 345)

2.)Caffeine may delay clients falling asleep and interfere with REM (rapid eye movement ) ( Doenges et al., 7th edition NCP, 345)

Reports that she could sleep for about 8 hours and rest for about

3.)Support continuation of usual bedtime rituals ( Doenges et al., 7th edition NCP, 345)

3.)Promotes falling asleep faster ( Doenges et al., 7th edition NCP, 345)

@130 cc/hr with 300cc level remainin g infusing well at patients right arm

COLLABORATIVE

1.)Administer analgesicssedatives at bedtime as indicated( Doenges et al., 7th edition NCP, 345)

1.)Some drugs help patient to easily fall asleep. ( Doenges et al., 7th edition NCP, 345)

2.)Collabrate to dietician the specific diet needed by the patient that would improve the sleeping habits. ( Doenges et al., 7th edition NCP, 345)

2.)Milk or foods that would make patients to fall asleep ( Doenges et al., 7th edition NCP, 345)

3.)Collaborate with the health care team about patients condition. ( Doenges et al., 7th edition NCP, 345)

3.)Identify and assesses the patient for other things that deprives sleeping pattern with the help of the health care team members ( Doenges et al., 7th edition NCP, 345)

DEPENDENT

1.)Administer medications as indicated for sleep, if applicable( Doenges et al., 7th edition NCP, 345)

1.)maybe effective on treating problems that includes sleeping patterns ( Doenges et al., 7th edition NCP, 345)

2.)Monitor for vital signs as ordered by the physician ( Doenges et al., 7th edition NCP, 345)

2.)continuous monitoring and prevents further complications ( Doenges et al., 7th edition NCP, 345)

3.)Use tranquilizers if necessary as ordered by the doctor. ( Doenges et al., 7th edition NCP, 345)

3.)Promotes sleep and interfering REM (Doenges et al., 7th edition NCP, 345)

CUES

NURSING DIAGNOSIS

SCIENTIFIC BASIS Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material. (Johnson, 2004)

GOALS &OUTCOME CRITERIA After 8 hours of varied nursing intervention, the patient will be able to exhibit normal skin integrity around the surgical incision. Specifically, the patient will: -report for abdominal in vital smelling pus.

NURSING ACTIONS & NURSING ORDERS INDEPENDENT: 1.)Assess skin area for color, swelling, pain, temperature and tugor. (Doenges, 2004)

RATIONALE

EVALUATION

SUBJECTIVE: Impaired skin Katol ang integrity related to tinahian sako surgical incision kilid nya naka.feel ko ug numbness sa surgical area, as verbalized by the patient.

1.) Redness, swelling, pain and hotness on the surgical area indicate for infection. ( Doenges, 2004)

After 8 hours of varied nursing interventions the goal was met. Patient was able to: -report for free of fever, changes in vital signs and foul-smelling drainage. -demonstrate techniques on correct management of the wound by cleaning and applying sterile gauze on the surgical incision. -identify signs and symptoms of infection.

OBJECTIVE: -disruption of skin surface -destruction of skin layer With the ff. v/s: T: 36.7 C PR: 91bpm RR: 22cpm BP: 130/90m mHg With ongoing

free of fever, 2.) Inspect skin on daily pain, change basis, describing lesions signs, foul- and changes observed. drainage or ( Doenges, 2004)

2.) Note for wound progression and identify for presence of infection. ( Doenges, 2004)

-demonstrate correct management of surgical incision 3.) Keep the area clean/dry and carefully -identify signs and dress the wound symptoms of infection. ( Doenges, 2004) 4.) Monitor for vital signs ( Doenges, 2004)

3.) Assist bodys natural process of repair. ( Deenges, 2004)

4.) Serve as baseline data and abnormalities may indicate signs of infection. ( Doenges, 2004)

IVF of # 7 PNSS 1L @130 cc/hr with 300cc level remainin g infusing well at patients right arm

DEPENDENT:

1.) Obtain specimen from 1.) Determine appropriate pus formations if there is. therapy. ( Doenges, 2004) ( Doenges, 2004)

CUES/ EVIDENCE SUBJECTIVE: kung naa pay pain score nga 20 day, 20 jud ang score sa sakit,, as verbalized by the patient. OBJECTIVE: With the ff. v/s: T: 36.7 C PR: 91bpm RR: 22cpm BP: 130/90m mHg With ongoing IVF of # 7 PNSS 1L @130 cc/hr with 300cc level remainin g infusing

NURSING DIAGNOSIS Alteration in comfort: Chronic pain r/t removal of FBC as evidenced by facial mask of pain, crying, guarding and abdominal heaviness.

SCIENTIFIC BASIS

GOALS AND OUTCOME CRITERIA Pain, chronic, GOAL: sudden or slow After 8 hours of onset of any rendering appropriate intensity from mild nursing interventions, to severe; constant the patient will be able or recurring to: without an -Verbalize relieve of anticipated or pain predictable end. Defining OUTCOME characteristics CRITERIA: include a verbal or Specifically, the client or coded report will be able to: observed evidence -Verbal reports of relief of protective of pain behaviour; -Report drop of pain guarding score from 10 to 0 or no behaviour; facial pain. mask; irritability; -Experience comfort. self- focusing; -Have a normotensive restlessness; BP, RR & PR depression; fatigue; reduced interaction with people; altered ability to continue previous activities; symphatic mediated responses

NURSING ACTIONS AND NURSING OEDERS INDEPENDENT 1.)Note for the location, scale, intensity and onset of pain

RATIONALE

EVALUATION

1.)To determine the nsg. care to be givento the pt.

After 8 hours of appropriate nursing care and intervention, the goal was met. The patient was able to: - Verbalize relieve of pain -Report drop of pain score from 10 to 0 or no pain. -Experience comfort. -Have a normotensive BP, RR & PR

2.)To minimize stimulus that could aggravate 2.)Maintain a calm and the condition of the pt. quite environment

3.)Use relaxation technique such as: heat and cold application

3.)To promote comfort and relaxation.

-Guide patient to perform deep breathing exercise -Provide good ventilation.

-Arrange things at bedside

-To offer a comfortable place to rest

-Provide a wrinkle-free bed

-To promote relaxation and

well at patients right arm Pain score of 10, 0 as no pain and 10 as the highest pain. Grimaced face noted Restlessn ess noted Distende d bladder observed Increased BP, RR and PR

(temperature, cold, changes of body position, hypersensitivity). Source: Mosbys pocket dictionary of medicine, nursing and health professions . Mosby Elsevier 5th edition Page 999

decrease discomfort -Explore nonpharmacological methods -To add comfort to the pt. : -back rubs -slow rhythmic breathing repositioning -diversional activities such as music, TV, etc.

DEPENDENT 1.) Offer analgesics q6 hrs prn (according to physician order).

1.)To reduce pain and promote comfort

COLLABORATIVE: -Encourage increase fluid intake of 2000 to 3000 mL of water per day