ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
Defining Characteristics Nursing Diagnosis Outcome Nursing Rationale Evaluation
Identification Interventions
Long term: Independent:
Subjective: Acute pain related to inflammatory Monitor vital signs To help determine Goals completely met.
“Tama ka sakit ang sa idalom process as evidenced by After 24 hours of patient’s current health Patient is able to:
sang akon tuo nga dughan (right positive murphy’s sign with palpable nursing intervention, status and evaluate Describe satisfactory pain
hypochondriac region) ” as tender gallbladder, unstable vital the patient will be able effectiveness of control at a level of 4 on a
verbalized by the patient signs and a pain scale of 8 out of 10 to show improved nursing intervention rating scale of 0 to 10.
well-being such as
baseline levels for
Assess pain, noting Provides information Show improved well-
location, intensity, and to aid in determining being such as baseline
pulse, BP, duration. choice or effectiveness
respirations, and levels for pulse, BP,
of interventions
Objective: relaxed muscle respirations, and
Pain scale of 8 out of 10 Rationale: tone or body Position the patient in Semi-Fowler’s relaxed muscle tone
Facial mask of pain/grimace The flow of bile in the gall bladder is posture a semi-Fowlers position reduces intra- or body posture
Guarding behavior obstructed due to the presence position abdominal pressure
Positive murphy’s sign with of stones. When the bladder releases and promote comfort
palpable tender gallbladder bile, it contracts and there is spasm,
thus it cannot adequately release bile Control environmental Cool surroundings aid
VS taken:
due to the stone, it stimulates the temperature in minimizing dermal
BP – 155/90mmHg
release of cytokines resulting to discomfort.
HR – 110bpm
pain.
RR – 14 breaths/m
Inform patient and SO This information helps
T – 38.1 °C
Note: Nursing Diagnosis should be of the expected establish realistic
base from (NANDA- Approved Short term: therapeutic effects and expectations,
Nursing Diagnosis) discuss management confidence in own
Within 4 hours of of side effects ability to handle what
nursing intervention happens
the patient will be able
to describes Provide comfort Promotes relaxation,
satisfactory pain measure like back rub, reduces alteration, and
helping patient assume may enhance coping
control at a level less position of comfort abilities
than 3 to 4 on a rating
scale of 0 to 10. Applying hot or cold Can be soothing and
compress relieve pain. It also
helps calm spasms and
relieve pressure from
bile buildup.
Use soft or cotton Reduces irritation
linens; calamine and dryness of the
lotion, oil bath; cool or
skin and itching
moist compresses as
indicated sensation
Encourage use of
stress management
Enables patient to
skills or
participate actively in
complementary
nondrug treatment of
therapies such as
pain and enhances
guided imagery
sense of control
Make time to listen to
and maintain frequent
Helpful in
contact with patient.
alleviating anxiety and
refocusing attention,
which can relieve pain
Maintain NPO status,
insert and/or maintain
NG suction as Removes gastric
indicated secretions that
stimulate release of
cholecystokinin and
gallbladder
contractions. To
prepare the patient
Dependent: for
Administer IV fluid of cholecystectomy
D5LR 1L x 125cc/hr
Provide To replace fluid losses
pharmacologic as volume per volume
ordered:
Rocephin
(Ceftriaxone) 2g
Q 24 hours
(Antibiotics) To treat
infectious process,
Flagyl reducing
(Metronidazole) 500 inflammation.
mg intravenously
Q 8 hours (Antibiotics) To treat
infectious process,
Tramadol reducing
Hydrochloride inflammation.
(Tramal) 50mg IV
Q 6 hours x 6 doses (Opioid) To reduce
then shift to Tramadol severe pain.
50mg capsule Q 6
hours PRN
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
Defining Characteristics Nursing Diagnosis Outcome Nursing Rationale Evaluation
Identification Interventions
Long term: Independent: Goals completely met.
Subjective: Risk for infection related to post- Within 3 days of Monitor v/s and To have a baseline Patient is able to:
operative incision nursing interventions, assess patient’s data. Achieve timely wound
the patient will be able condition. healing, free from
to achieve timely purulent drainage, and
wound healing, be free Note risk factors To help the patient stay afebrile.
Rationale: of purulent drainage, for occurrence of identify the present
Objective: The patient is at risk of acquiring and be afebrile. infection in the risk factors that may Demonstrate techniques
Patient may manifest: infection due to the break in the incision add up to the infection in reducing risk of having
Inadequate secondary defenses continuity of the first line defense infection.
Insufficient knowledge to avoid which is the skin. The patient had Stress proper hand A first line defense
exposure to pathogen undergone cholecystectomy, thus washing techniques against nosocomial
there is an incision and suture made infection or cross
in the abdomen. If there is a contamination
breakage in the skin, the pathogens Short term:
will easily invade After 2 hours of Increase oral fluid To hasten wound
the body’s system nursing interventions, intake if not healing
thus, increasing risk for infection. the patient will be able contraindicated
to demonstrate
techniques in reducing Strict compliance to To establish
Note: Nursing Diagnosis should be risk of having hospital control, mechanism to prevent
base from (NANDA- Approved infection. sterilization, and occurrence
Nursing Diagnosis) aseptic policies of infection
Observed for localized To evaluate if the
sign of infection at character, presence
insertion sites of and condition of
invasive lines, surgical the present infection
incisions or wounds.
Tell patient to comply To prevent the
to antibiotic therapy as occurrence
prophylaxis of infection
Monitor medication To determine
regimen effectiveness of
therapy
Make health To help the patient
teachings especially in modify/change/avoid
identification some of the
of environmental environmental
risk factors that could factors present which
add up on infection. could reduce the
incidence of infection
Dependent:
Administer IV fluid of To replace fluid losses
D5LR 1L x 125cc/hr volume per volume
Provide
pharmacologic as
ordered:
Rocephin (Antibiotics) To treat
(Ceftriaxone) 2g infectious process,
Q 24 hours reducing
inflammation.
Flagyl (Antibiotics) To treat
(Metronidazole) 500 infectious process,
mg intravenously reducing
Q 8 hours inflammation.
