CUES

Subjective: The incision is really painful especially kapag gumagalaw ako, as verbalized by the client. Objective: -Status quo post open cholecystectomy -Surgical incision -Pain scale of 6 -Protective behavior/guarding -Facial grimace

NURSING DIAGNOSIS
Acute pain related to surgical incision secondary to cholecystectomy

RATIONALE
Cholecystectomy is the removal of the gallbladder through a surgical incision. Pain is whatever the experiencing person says it is, existing whenever the person says it does; unpleasant sensory and emotional experience arising from actual or potential tissue damage. Ref: Brunner & Suddarths Textbook of Medical-Surgical Nursing: 11th d., p.1345

GOAL & OBJECTIVES

After 4 hour of nursing interventions, the client will experience diminished pain as evidenced by: a. verbalization of a decrease in pain b. verbalization of methods that provide relief c. demonstration of relaxation skills and diversional activities d. increased participation in activities e. relaxed facial expression

NURSING INTERVENTIONS
-Asses pain including location, duration, frequency and severity. -Provide quiet environment.

RATIONALE
-To asses etiology/precipitating contributory factors and data baseline -To help alleviate/control pain by providing decreased stimuli -Promotes relaxation and assists in decreasing pain response. Provides diversion from pain. Decreases anxiety and muscle tension. Increases comfort and empowers the patient.

EVALUATION
After 4 hour of nursing interventions, the goal was fully met. The client experienced diminished pain as evidenced by:
a. verbalization

-Teach client nonpharmacological pain management such as: - heat or cold therapy - biofeedback - progressive relaxation - guided imagery - rhythmic breathing - distraction - contralateral stimulation - stress reduction techniques - self-hypnosis - proper positioning - therapeutic touch - yoga or tai chi

b. c.

d. e.

of a decrease in pain (pain scale of 0) verbalization of methods that provide relief demonstration of relaxation skills and diversional activities increased participation in activities relaxed facial expression

-Identifies need to have

-Develop daily plans for pain management to determine those that might be suited for the patient to use on regular basis.

several alternate plans to deal with pain.

-Teach the client and family factors that decrease tolerance to pain and methods for decreasing these factors - lack of knowledge regarding disease process - lack of support from significant others - fear of addiction or loss of control - fatigue - boredom - improper positioning -Pain medications are absorbed & -Give analgesics as metabolized differently ordered, evaluating by patients, so the effectiveness & effectiveness must be observing for any signs evaluated individually and symptoms of by the patient. untoward effects.

-Reducing these factors can increase the tolerance to pain.

CUES
Subjective: Hindi ako makahinga ng maayos because when I inhale, sumasakit yung tahi, as verbalized by the client. Objective:
Status quo

NURSING DIAGNOSIS
Difficulty of Breathing related to the high abdominal surgical incision secondary to cholecystectomy

RATIONALE
The location of the incision in gallbladder surgery often causes the client patient to take shallow breaths to prevent pain. Ref: Brunner & Suddarths Textbook of Medical-Surgical Nursing: 11th d., p.1356

GOAL & OBJECTIVES

After 1 hour of nursing interventions, the client will experience improved respiratory status as evidenced by:
a. verbalization

NURSING INTERVENTIONS
-Monitor and document. - respiratory pattern, rate, and depth - pain, DOB, retraction of sternum or flaring of nares -Raise head of bed to 30o or more.

RATIONALE
-Baseline factors that will allow assessment of the patients progress toward improvement

EVALUATION
After 1 hour of nursing interventions, the goal was fully met. The client experienced improved respiratory status as evidenced by: a. verbalization of relieved pain while breathing b. demonstration of methods to prevent pain while breathing c. understanding of oxygen supplementatio n and other interventions

-Facilitates chest expansion. -Relaxes muscle tension, decreases oxygen consumption, and decreases carbon dioxide production.

post open cholecystectom y RR = 18 Shallow breathing Nasal flaring

of relieved pain while breathing -Reduce chest pain by b. demonstration using noninvasive of methods to techniques: prevent pain - diaphragmatic while breathing deep breathing c. understanding - pursed-lip of oxygen breathing supplementatio - progressive n and other relaxation interventions - rhythmic breathing - proper positioning

CUES
Subjective: Kailangan pa nila na buksan ang tiyan ko para lang kunin ang bato doon at maoperahan lang ako, as verbalized by the client. Objective:
Status quo

NURSING DIAGNOSIS
Risk for Infection related to an invasive procedure

RATIONALE
Having breaks in the integument, the bodys first line of defense allow invasion by pathogens. Theres a risk for infection when theres an increased risk for being invaded by pathogenic organisms. Ref: Brunner & Suddarths Textbook of Medical-Surgical Nursing: 11th d., p.545

GOAL & OBJECTIVES

After 1 hour of nursing interventions, the client will remain free from invasion of pathogenic organisms as evidenced by: a. absence of signs of infection b. verbalization of symptoms of infection c. demonstration of methods to decrease risk for infection

NURSING INTERVENTIONS
-Monitor and document vital signs.

RATIONALE
-Provides baseline that allow recognition of deviations in subsequent measurements. -Avoids overheating or overcooling of room that would contribute to complications. -Prevents crosscontamination and nosocomial infection.

EVALUATION
After 1 hour of nursing interventions, the goal was fully met. The client remained free from invasion of pathogenic organisms as evidenced by: a. absence of signs of infection b. verbalization of symptoms of infection c. demonstration of methods to decrease risk for infection

-Maintain a neutral environment.

-Wash your hands thoroughly between each treatment. Teach the patient the value of frequent handwashing. -Use sterile technique when changing dressings. -Keep linens and underpads clean and changes as necessary. -Inform the client the signs of infections - inflammation, heat, pain, redness, etc.

post open cholecystectom y Fresh surgical incision

-Protects the patient from exposure to pathogens. -Reduces the likelihood of nosocomial infections. -Provides basic knowledge for self-help and self-protection.