Nursing Care Plan Preoperative NCP 1.

Acute Pain Cues Nursing Diagnosis S Acute pain related to O inflammation -pain scale and of 7/10 distortion of -difficulty the in moving gallbladder as as evidenced manifested by verbal by facial reports of grimaces pain. -(+) pallor -(+) muscle guarding -RR - 30 -BP - 140/90 Scientific Explanations Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute pain on the right part of the abdomen. Objectives After 4 hours of nursing intervention the patient will report relieve of pain. Nursing Interventions 1.Observe and document location, severity (010 scale),and character of pain (e.g., steady, intermittent, colicky). 2. Promote bedrest, allowing patient to assume position ofcomfort. 3. Control environmental temperature. 4. Encourage use of relaxation techniques, e.g., guidedimagery, visualization, deep-breathing exercises. Providediversional Rationale - Assists in differentiating cause of pain, and providesinformation about disease progression/resolution,development of complications, and effectiveness ofinterventions. - Bedrest in low-Fowlers position reduces intra-abdominalpressure; however, patient will naturally assume leastpainful position. - Cool surroundings aid in minimizing dermal discomfort. - Promotes rest, redirects attention, may enhance coping. - Helpful in alleviating anxiety and refocusing attention,which can relieve pain. - Relief of pain facilitates cooperation with othertherapeutic interventions, Evaluation Is there a change on the patients;a.Pain scaleb.RRc.BPd.Reports of paine.Facial expressions.

activities. 5. Make time to listen to and maintain frequent contact withpatient.6. Administer analgesics as indicated

2. Fluid Volume deficient Cues S O -(+) pallor -(+) body weakness -(+) vomiting -with poor skin turgor -(+) dry skin -(+) dry mouth Nursing Diagnosis Fluid Volume Deficient related to vomiting Scientific Explanations Because of vomiting excessive losses through normal routes occur thus causes Fluid Volume Deficient Objectives After series of NI the pt. will maintain adequate fluid volume as evidenced by moist mucous membranes and good skin turgor Nursing Interventions 1. Maintain accurate record of I&O, noting output less thanIntake, increased urine specific gravity. Assessskin/mucous membranes, peripheral pulses, and capillaryrefill. 2. Perform frequent oral hygiene 3. Provide skin and mouth care 4. Increase fluid intake 5. Ascertain patients beverage preferences, and Rationale Evaluation

- Provides information Is there still about fluid the presence status/circulatingvolume of; and replacement needs. a.vomiting - Decreases dryness of oral mucous b.dry skin membranes; reducesrisk of oral bleeding. c.dry mouth - Skin and mucous membranes are dry, with decreasedelasticity, because of vasoconstriction and reducedintracellular water. d.poor skin turgor e.body weakness

set up a 24-hr schedule for fluid intake. Encourage foods with highfluid content.

6. Administer antiemetics, e.g., prochlorperazine(Compazine) as ordered by the physician. - Reduces nausea and prevents vomiting.

- promotes hydration.Relieves thirst and discomfort of dry mucous membranesand augments parenteral replacement.

Post-operative NCP 3. Knowledge Deficit Cues S pwede bang maulit ang sakit ko as verbalized by the patient O -Frequently asking question about his condition, treatment and diet -With worried gaze Nursing Diagnosis Scientific Explanations Deficient There is this knowledge related presence of to knowledge condition,prognosis, deficit due to treatment, selfsome care, and discharge unfamiliar needs information that causes some confusion to the client that needs to be discussed. Objectives Nursing Interventions After an hour of 1. Provide nurse-patient explanations interaction the of/reasons for test patient will procedures Verbalize andpreparation understanding needed. of disease process, 2. Review disease prognosis, and process/prognosis. potential Discuss complications. hospitalizationand prospective treatment as indicated. Encouragequestions, expression of concern. 3. Review drug regimen, possible side effects. 4. Instruct patient to avoid food/fluids high in fats (e.g.,whole milk, ice cream, butter, fried foods, nuts, Rationale - Information can decrease anxiety, thereby reducingsympathetic stimulation. - Provides knowledge base from which patient can makeinformed choices. Effective communication and supportat this time can diminish anxiety and promote healing. - Gallstones often recur, necessitating long-term therapy. - Prevents/limits recurrence of gallbladder attacks. Evaluation -Does the patient understands and could recall all the teachings given? -Is there a significant changes that occur on the patients knowledge regarding; a.disease condition

b.diet - Promotes gas formation, which can increase c.treatment gastricdistension/discomfort. d.medication e.self-care needs

gravies,pork), gas producers (e.g., cabbage, beans, onions,carbonated beverages), or gastric irritants (e.g., spicyfoods, caffeine, citrus). 5. Suggest patient limit gum chewing, sucking on straw/hardcandy, or smoking.

b.Drug Study Name of Drug GN: H2Bloc (Pepcidine)BN: Famotidine Date Ordered Route/ Dosage and Frequency PO20 mg tab at bedtime Action - Anti-ulcercompetitively inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion Indication -for short term treatment of duodenal ulcer Adverse Reaction - headache, dizziness, malaise, dry mouth Nursing Consideration 1. Check for doctors order2. not to be given in patients hypersensitive to drugs3. Inform the patient about the possible side effect of the drug4. Instruct patient to take drug with food5. Advised patient to take drug once

GN: CefuroximeBN: Zinacef

IV750 mg every 8 o prior to OR (30 to 60 minutes before)

- anti-infective- a 2 nd generation cephalosporin that inhibits cell -wall synthesis, promoting osmotic instability

- perioperative prophylaxis

- Nausea and Vomiting

GN: Clomipramine HClBN: Placil

PO10 mg tab, at 6 am

- Anti-depressants

- for depression and chronic pain

- headache, dizziness, malaise, dry mouth

GN: Gentamicin DulfateBN:

IV80 mg amp, every 8

- Anti-infectiveinhibits protein

- endocarditis prophylaxis for GI

- Nausea and Vomiting,

daily usually at bed time6. Advise patient to report abdominal pain or blood in stools or is vomiting 1. Check for doctors order2. Perform ANST prior to admission3. Should not be given if positive skin test4. Slow IV push5. Inform the patient about the possible side effect of the drug6. Advise patient to report any discomfort on the IV insertion site 1. Check for doctors order2. not to be given in patients hypersensitive to drugs3. Inform the patient about the possible side effect of the drug 1. Check for doctors order

Genticin

synthesis

or GU procedure or surgery

headache, dizziness

GN: AmpicillinBN: Omnipen

IV1 g amp, every 8 0

- Anti-infectiveinhibits protein synthesis

- endocarditis prophylaxis for GI or GU procedure or surgery

- Nausea and Vomiting, headache, dizziness

2. Perform ANST prior to admission 3. Should not be given if positive skin test 4. Slow IV push 5. Inform the patient about the possible side effect of the drug 6. Advise patient to report any discomfort on the IV insertion site 7. Monitor urine output, specific gravity, U/A, BUN and creatinine levels 1. Check for doctors order2. Perform ANST prior to admission3. Should not be given if positive skin test4. Slow IV push5. Inform the patient about the possible side effect of the drug6. Advise patient to report any discomfort on

GN: MgSO4

IV0.03% 7ml every 12

-anti-convulsant -replaces magnesium and maintains magnesium level

- magnesium supplementation

- drowsiness, hypotension

GN: Ketorolac TromethamineBN: Toradol

IV30 mg amp, every 6

- Antiinflammatory inhibits prostaglandin synthesis

- short term management of moderately severe, acute pain

- dizziness, sedation, headache, flatulence, nausea and vomiting

the IV insertion site 1. Use parenteral magnesium with extreme caution in patients with impaired renal function2. Test knee jerk and patellar reflexes before each additional dose3. check magnesium level after repeated doses4. Monitor fluid intake and output5. Monitor renal function 1. Check for doctors order 2. Perform ANST prior to admission 3. Should not be given if positive skin test 4. Slow IV push 5. Inform the patient about the possible side effect of the drug 6. Advise patient to report any discomfort on the

IV insertion siteAnesthetic drug

Anesthetic drug Action GN: Lidocaine HCl IV Anesthetic drugs Adverse Reaction -lethargy, hypotension Nursing Consideration 1. Monitor BP, PR, and RR before and after giving the medication2. Monitor patient for toxicity