B.

ACTUAL NURSING MANAGEMENT 1st day, assessment 2nd day, assessment

S O A P I E

Sakit kaayo akong tibook likod ug tiyan as verbalized.

Facial grimace Pain Scale of 8/10, spasmic pain all over the abdominal area Guarding on the abdominal area Self focusing; narrowed focused

Acute Pain related to the presence of gallstones in the gallbladder

Long Term: At the end of 8 hours of nursing interventions, patient will be relieved from pain felt. Short Term: At the end of 30 minutes of nursing interventions, patient will report pain is tolerable. Encouraged deep breathing exercise during onset of pain Promoted bed rest and in low fowlers position Provided comfort measures (change of position every 2 hours, therapeutic touch) Encouraged use of diversional activities like watching tv, listening to the radio. Administered medication as prescribed (Tramadol 50 mg slow IVTT, q8 x 3 doses then PRN) by Nurse on Duty Long Term: After 8 hours of nursing interventions, the patient verbalized pain was relieved

Short Term: After 30 minutes of nursing interventions, the patient reported that the pain was tolerable

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dili kaayu ko makatulog kung mutukar ang sakit as verbalized.

Change in normal sleep pattern Restless Irritable

Disturbed Sleep Pattern related to environmental factors( noise, ambient temperature)

Long term: At the end of 1 day of nursing intervention n, the patient will be able to report improve sleep and increase sense of wellbeing. Short term: At the end of 4 hours of nursing intervention the patient will be able to identify interventions to promote sleep. Provided a quiet environment Provided comfort measures (touch therapy, cleaning and straightening beddings) Use of sleep aids (personal pillows) Instructed to establish routine bed time and arising, think relaxing thoughts when in bed, do not nap in the daytime Adequate rest provided

Long term: After 1 day of nursing intervention, patient have been able to improved sleep and increased sense of well-being. Short term: After 4 hours of nursing intervention, the patient was able to identify interventions to promote sleep.

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Dili kaayo ko kalihok maam kay sakitan ko as verbalized.

facial grimace guarding sleep disturbance Activity Intolerance related to pain on movement

Long term: After 2 days of nursing interventions, the patient will be able report measurable increase in activity tolerance Short term: After 1day of nursing interventions, the patient will to identify techniques to enhance activity tolerance Properly positioned the patient to avoid straining affected areas in the body Assisted patients needs Assisted ADLs to help reduce discomfort and avoid too much energy exertion Encouraged frequent position changes (side-lying to supine) when on bed rest Encouraged bed rest Long term: After 2days of nursing interventions, the patient was able to report measurable increase in activity tolerance manifested by walking without assistance. Short term: After 1 day of nursing interventions, the patient was able to identify techniques to enhance activity tolerance

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Gakakulbaan ko sa akong operasyon karon kay last nako nga opera, gi-intubate man gud ko as verbalized Verbalize awareness of feelings Anxious Restlessness Preoccupied from her last operation experience Anxiety related to upcoming operation

Long term: After 1 hour of nursing interventions, the patient will appear relaxed and report anxiety reduced to a manageable level. Short term: After 30 minutes of nursing interventions, the patient will verbalize awareness of feelings of anxiety Established a therapeutic relationship, conveying empathy and unconditional positive regard. Be available to client for listening and talking Encouraged client to acknowledge and to express feelings Providedinformation regarding disease process and anticipated treatment Provided comfort measures(e.g., calm/quiet environment, therapeutic touch) Provided adequate rest Instructed in ways to use positive talk, e.g., I can handle this Long term: After 1 hour of nursing interventions, the patient appeared relaxed and reported reduced anxiety manifested by socialization engagement(talking with other patients and laughing with them). Short term: After 30 minutes of nursing interventions, the patient was able to verbalize understanding of her present health status that lessened her anxiety.

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gasakit akong tahi kung mulihok ko as verbalized by patient

(+) Facial grimace Pain scale of 5 out of 10, Self-focusing; narrowed focus

Acute pain related to post-op surgical incision

Long term: After 8 hours of nursing interventions, the patient will demonstrate techniques to alleviate/control pain. Short term: After 30 minutes of nursing interventions, the patient will report relief of pain Encouraged deep breathings during onset of pain Positioned client to where she is comfortable Taught client diversional activities like watching television Have the patient splint incision when moving Provided adequate rest periods Provided a calm, quiet environment Administered analgesic (ketorolac 300 mg IVTT,q6 x 4 doses) by Nurse on Duty Long term: The patient was able to demonstrate techniques to alleviate pain Short term: The patient reported that the pain was lessened

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gasakit akong tahi kung mulihok ko as verbalized by patient

Sugical dressing on RUQ Disruption of the skin surface Injury on the skin layers

Impaired skin integrity related to surgical incision

Long term: After 2 days of nursing interventions, the patient will achieve timely wound healing without complications Short term: After 1 day of nursing interventions, the patient will demonstrate behaviors to promote healing/prevent skin breakdown Changed dressings and do wound care as often as necessary Placed patient in low- or semi-Fowlers position Maintained T-tube in closed collection system Administered antibiotics(cefuroxime 350 mg, IVTT q8) by Nurse on Duty Long term: After 2 days of nursing intervention, the patient was able to maintained the wound intact and free from complications Short term: After 1 day of nursing intervention, the patient verbalized understanding of proper wound care and demonstrated the proper way to do it.

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Slightly febrile (37.7 degrees celcius) WBC : 13.7 (4.50-11.0) x 10^ g/uL Presence of post-operative wound at right upper quadrant of the abdomen With penrose drainage

Risk for infection related to presence of post-operative wound

Long term: After 8 hours of nursing interventions, the patient will demonstrate techniques in reducing risk of having infection. Short term: After 4 hours of nursing interventions, the patient will achieve timely wound healing, be free of purulent drainage, be afebrile.

Stressed proper hygiene Emphasized importance of daily change dressings Increased oral intake Maintained adequate nutrition ( Maintained adequate rest

Long term: After 8 hours of nursing interventions, the patient was able to demonstrate techniques in reducing risk of having infection Short term: After 4 hours of nursing interventions, the patient was afebrile and free from purulent drainage.