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 (0–10 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-Fowler’s 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.
a. c.vomiting . peripheral pulses. and Rationale Evaluation
. Perform frequent oral hygiene 3. Increase fluid intake 5. 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.Provides information Is there still about fluid the presence status/circulatingvolume of. reducesrisk of oral bleeding. will maintain adequate fluid volume as evidenced by moist mucous membranes and good skin turgor Nursing Interventions 1. Provide skin and mouth care 4.6. 2.body weakness
. Maintain accurate record of I&O. Ascertain patient’s beverage preferences.dry skin membranes. and replacement needs. noting output less thanIntake.Skin and mucous membranes are dry. 5.dry mouth . Administer analgesics as indicated
2. increased urine specific gravity. Assessskin/mucous membranes.activities.Decreases dryness of oral mucous b. Make time to listen to and maintain frequent contact withpatient. with decreasedelasticity.poor skin turgor e. because of vasoconstriction and reducedintracellular water. and capillaryrefill. d.
g.Relieves thirst and discomfort of dry mucous membranesand augments parenteral replacement.
6. prochlorperazine(Compazine) as ordered by the physician.Reduces nausea and prevents vomiting.promotes hydration.
.set up a 24-hr schedule for fluid intake. Administer antiemetics. .
.. Encourage foods with highfluid content. e.
. possible side effects.medication e. . selfsome care. Review disease prognosis. butter.Gallstones often recur. thereby reducingsympathetic stimulation. a.disease condition
b.Promotes gas formation. . Instruct patient to avoid food/fluids high in fats (e. Knowledge Deficit Cues S “pwede bang maulit ang sakit ko” as verbalized by the patient O -Frequently asking question about his condition. . deficit due to treatment. Effective communication and supportat this time can diminish anxiety and promote healing. ice cream. Rationale . Review drug regimen. Encouragequestions. expression of concern. which can increase c. and process/prognosis. 4.whole milk. Evaluation -Does the patient understands and could recall all the teachings given? -Is there a significant changes that occur on the patients knowledge regarding. d.diet . treatment and diet -With worried gaze Nursing Diagnosis Scientific Explanations Deficient There is this knowledge related presence of to knowledge condition.Post-operative NCP 3. and discharge unfamiliar needs information that causes some confusion to the client that needs to be discussed.self-care needs
.g. nuts.Prevents/limits recurrence of gallbladder attacks. 2. 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. potential Discuss complications. fried foods.prognosis.treatment gastricdistension/discomfort.Information can decrease anxiety. necessitating long-term therapy. hospitalizationand prospective treatment as indicated. 3.Provides knowledge base from which patient can makeinformed choices.
sucking on straw/hardcandy. caffeine. or gastric irritants (e..Anti-ulcercompetitively inhibits action of histamine on the H2 at receptor sites of parietal cells. Suggest patient limit gum chewing. citrus).g.. beans. malaise.pork).Drug Study Name of Drug GN: H2Bloc (Pepcidine)BN: Famotidine Date Ordered Route/ Dosage and Frequency PO20 mg tab at bedtime Action .headache.
b.g. spicyfoods. dizziness. onions. or smoking.carbonated beverages). dry mouth Nursing Consideration 1. gas producers (e. decreasing gastric acid secretion Indication -for short term treatment of duodenal ulcer Adverse Reaction . Inform the patient about the possible side effect of the drug4. Advised patient to take drug once
. cabbage.gravies. not to be given in patients hypersensitive to drugs3. Check for doctor’s order2. Instruct patient to take drug with food5. 5.
Check for doctor’s order2.Nausea and Vomiting. Advise patient to report abdominal pain or blood in stools or is vomiting 1.anti-infective. Slow IV push5. dry mouth
GN: Gentamicin DulfateBN:
IV80 mg amp.endocarditis prophylaxis for GI
. Check for doctor’s order
. dizziness. malaise. not to be given in patients hypersensitive to drugs3.GN: CefuroximeBN: Zinacef
IV750 mg every 8 o prior to OR (30 to 60 minutes before)
. Advise patient to report any discomfort on the IV insertion site 1. promoting osmotic instability
. Perform ANST prior to admission3.for depression and chronic pain
.headache. at 6 am
. every 8
. Should not be given if positive skin test4.perioperative prophylaxis
. Check for doctor’s order2.a 2 nd generation cephalosporin that inhibits cell -wall synthesis.
daily usually at bed time6.Nausea and Vomiting
GN: Clomipramine HClBN: Placil
PO10 mg tab. Inform the patient about the possible side effect of the drug 1. Inform the patient about the possible side effect of the drug6.
2. Perform ANST prior to admission 3. Slow IV push5. Perform ANST prior to admission3. Slow IV push 5. Inform the patient about the possible side effect of the drug6. Monitor urine output. every 8 0
. Should not be given if positive skin test 4. Advise patient to report any discomfort on
. Check for doctor’s order2.Nausea and Vomiting. specific gravity.Anti-infectiveinhibits protein synthesis
. Advise patient to report any discomfort on the IV insertion site 7. headache.endocarditis prophylaxis for GI or GU procedure or surgery
. Inform the patient about the possible side effect of the drug 6. U/A. dizziness
GN: AmpicillinBN: Omnipen
IV1 g amp.Genticin
or GU procedure or surgery
headache. BUN and creatinine levels 1. Should not be given if positive skin test4.
Perform ANST prior to admission 3. acute pain
. Slow IV push 5. nausea and vomiting
the IV insertion site 1. Check for doctor’s order 2. Use parenteral magnesium with extreme caution in patients with impaired renal function2. Monitor fluid intake and output5.GN: MgSO4
. Should not be given if positive skin test 4.dizziness. check magnesium level after repeated doses4. Test knee jerk and patellar reflexes before each additional dose3.03% 7ml every 12
-anti-convulsant -replaces magnesium and maintains magnesium level
. flatulence.drowsiness. headache.Antiinflammatory inhibits prostaglandin synthesis
GN: Ketorolac TromethamineBN: Toradol
IV30 mg amp.short term management of moderately severe. Monitor renal function 1. Advise patient to report any discomfort on the
. every 6
. Inform the patient about the possible side effect of the drug 6. sedation.
PR. Monitor BP. and RR before and after giving the medication2. hypotension Nursing Consideration 1. Monitor patient for toxicity
.IV insertion siteAnesthetic drug
Anesthetic drug Action GN: Lidocaine HCl IV Anesthetic drugs Adverse Reaction -lethargy.