Cues/Needs

Subjective: “kumikirot kirot yun opera sakin” as verbalized by the patient. Objective: -Pain scale: 8/10 (10 as the highest) -Facial grimace -Guarding behavior over the abdomen -Restlessness -Pupillary dilation V/S BP: 130/90 mmHg PR: 87 RR: 25 T: 37

Nursing Diagnosis
Acute pain related to post operative incision secondary to laparoscopic cholecystecto my.

Rationale
Unpleasant sensory and emotional experience arising from actual tissue damage through incision or breaking of skin, especially abdominal layers.

Goals and Objectives
After 30 minutes of nursing interventions, the patient will: -Report pain alleviation from severe pain 8/10, to moderate pain 34/10, or totally relieved from pain. - Identify and use appropriate interventions to manage pain and discomfort. - Appear relaxed, able to rest/ sleep and participate in activities appropriately

Nursing Interventions
-Assess pain, character, location, severity, precipitating and relieving factors and duration; use a pain rating scale. - Encourage use of relaxation technique.

Rationale
-Pain assessment can provide clues about diagnosis; used to determine treatment required.

Evaluation
After 30 minutes of nursing interventions, the goal was met as the patient able to: -Report moderate pain of 3/10

A- delta myelinated fiber perceive a sharp pain when noxious thermal or mechanical stimulation occurs. When mechanical stimuli activate the unmyelinated C fiber, the cutaneous pain is felt as long lasting, burning pain or sharp pain

- Promotes rest, redirects attention, may enhance coping. -Helps to provide support to the incision and decrease pain. Splinting provides incision support/ decreases muscle tension to promote cooperation with therapeutic regimen -Relaxation exercise: technique used to bring about a state of physical and mental awareness and tranquility. Massage: decreases muscle tension and can promote comfort. Distraction: heightening one’s concentration upon non painful stimuli to develop one’s awareness and experience of pain. -Bed rest in low fowler’s position reduces intra abdominal pressure.

-Have the patient splint incision when moving

-Identify and use appropriate interventions to manage pain and discomfort -Appeared relaxed, able to rest/ sleep and participate in activities appropriately

References: M.Doenges M. moorhouse A.Murr Nanda p.498

-Encourage use of alternative methods of pain relief such as relaxation exercises (deep-breathing exercise), massage and distraction.

Focus on pathophysiology by: Barbara Bullock Reet L. Henze p. 1053

-Promote bed rest and in low fowler’s position

-Control environmental

Cues/Needs
Subjective Data “Nahihirapan ako huminga lalo na pag kumikirot yun sakin sa tyan ko” as verbalized by the patient. Objective data Unable to breathe normally Cold both upper and lower extremities RR- 24 cpm O2 Saturation88 percent

Nursing Diagnosis
Ineffective breathing pattern related to pain on post operative site

Rationale
Due to the pain felt after the laparoscopic cholecystectomy operation, there is a decreased lung expansion and decreased respiratory depth/vital capacity that causes inadequate ventilation for the client .

Goals and Objectives
After 30 minutes of nursing intervention, the client will be able to establish a normal effective respiratory pattern

Nursing Interventions
-Administer oxygen at the lowest concentration. -Elevate head of bed, place client in semi-fowlers position. -Encourage slower deeper respiration with the use of pursed lip technique and deep breathing exercise. -Monitor the pulse oximeter -Encourage adequate rest period between activities -Administer medication prescribed by the physician such as analgesics.

Rationale
-For management of underlying pulmonary condition, respiratory distress or cyanosis. -To promote physiological/ psychological ease of maximal inspiration. -To assist client in ‘taking control’ of the situation.

Evaluation
After 30 minutes of nursing intervention, the goals are met as evidence by establishing a normal/ effective respiratory pattern with respiratory rate of 20cpm and oxygen saturation of 100 percent.

-To verify the improvement and maintenance of oxygen saturation. -To limit fatigue.
-To promote deeper respiration

Reference: NANDA Edition 11 p. 143

Cues/Needs

Nursing Diagnosis
Impaired skin integrity related to surgical incision on abdomen secondary to laparoscopic cholecystectomy .

Rationale

Goals and Objectives
After 4 hours of nursing intervention, the patient will remain free from infection and bleeding.

Nursing Interventions
-Monitor surgical site for any signs and symptoms of infection.

Rationale

Evaluation

Subjective: “May tahi ako sa tyan dahil sa opera ko minsan kumakati sya pero iniiwasan kong makamot” as verbalized by the patient. Objective: Ruptured skin Facial grimace Incision Disruption of skin surface - Presence of sutures

An invasive procedure makes an open incision on an area of the body to allow a clear view of the underlying or the organs underneath the skin and may be a therapeutic approach to allow drainage of discharges on the operative site.

-Early identification of poor wound healing or infection can expedite treatment.

-Apply pressure to the incision site

-Establish hemostasis, and prevents bleeding

After 4 hours of nursing intervention, the goal is fully met as evidenced by patient remained free from infection and did not exhibit excessive bleeding.

- Maintaining clean, dry skin provides a barrier to - Demonstrated good infection. Patting skin skin hygiene, ( wash dry instead of rubbing thoroughly and pat dry reduces risk of dermal the skin surrounding the trauma to fragile skin
wound carefully)

Reference: p. 778-780 Nursing care plans guidelines for individualizing patient care, 6th ed By: Doenges

- change dressings on incision and over drainage tube insertion sites, or puncture sites. Clean area using sterile technique. - Emphasized importance of adequate fluid intake. -Encourage adequate nutritional intake, especially of protein, vitamin C and iron.

-maintenance of clean incision site decreases number of organisms and reduces chance of infection.

- Improved nutrition and hydration will improve skin condition -Adequate nutrient intake, especially of vitamin C, protein and iron, is required for healing and tissue repair.

-Maintain patency of

-The drainage device helps prevent

Cues/Needs

Nursing Diagnosis

Rationale

Goals and Objectives

Nursing Interventions

Rationale

Evaluation

Subjective Data: “Nahihirapan ako gumalaw dahil sa tahi ko sa tayan, kumikirot kase madalas eh.” Objective Data: - Limited range of

Impaired physical mobility related to pain at incision site

Pain impairs mobility and activity. Full function may be affected and be delayed. Source:

Pain impairs mobility and activity. Full function may be affected and be delayed. Source: Monks. Home health nursing: assessment and care planning. Elsevier Health

-Change position frequently when on bedrest; support affected body parts or joints with pillows.

After 8 hours of nursing intervention, the the goal was half met as evidenced - Encourage -To permit maximal by : client: appropriate use of effort or involvement in 1. Refused to do assistive devices in activity. other activites the home setting. because of fear to experience pain -Provide skin -Decreases discomfort, after the activity. massage. Keep skin maintains muscle

-Mobility aids can increase level of mobility.

motion. - not able to move freely. - slowed movement. - Pain scale of 8/10

Sciences, 2002

clean and dry well. strength/ joint mobility, Keep linens dry and enhances circulation wrinkle-free. and prevents skin breakdown. -Encourage deep -Stimulates circulation breathing and and prevents skin coughing. Elevate irritation. head of bed Turn side Mobilizes secretions, to side. improves lung expansion and reduces risk of respiratory complications. -Encourage early ambulation. Support -Early ambulation abdomen when prevents postop ambulating. complications. Splinting provides incisional support/ decreases muscle tension to promote cooperation with therapeutic regimen. Provide adequate rest periods in between activities. - Provide safe environment such as giving assistance in sitting and transferring from bed to chair or chair to bed and use of wheelchair if possible. -Encourage patient to

2. has no contractures and complications observed after an 8 hour care.

Reference: Monks. Home health nursing: assessment and care planning. Elsevier Health Sciences, 2002

-Avoids accidental injuries and falls.

discuss feelings and concerns about her altered state of mobility

-To prevent anxiety and promote compliance

Cues/Needs

Nursing Diagnosis

Rationale

Subjective: “ano ba yun mga dapat kong gawin pagkatpos ng operasyon ko” as verbalized by the client.
References: M.Doenges M. moorhouse A.Murr Nanda p.498

Deficient knowledge about self care activities r/t incision care, dietary modifications, medications reportable signs and symptoms

Laparoscopic Cholecystectomy is the surgical removal of the infected gall bladder. The client has a deficiency of cognitive information related to specific topic such as self care activities about incision care, dietary modification, and prognosis and discharge plan.

Goals and Objectives After 1- 2 hours of interventions, the patient will be able to verbalize an understanding of the operative procedure and prescribed postoperative regimens.

Nursing Interventions

Rationale

Evaluation

- Assess readiness of patient to learn (motivation, cognitive level , and physiological status).

-The patient must be motivated to learn, have the capability to learn the content, and be free of distractions fro learning, such as pain and emotional distress.

After 1- 2 hours of interventions, the goal was fully met, patient was able to verbalize an understanding of the operative procedure and prescribed postoperative regimens. “Kailangan pala sundin yun mga instructions doctor para mas mapadali yung pagrecover ko” as verbalized bythe patient.

- Create a quiet environment conducive to learning.

Presence of incision on the abdomen due to post-operative done

- Environmental noise can prevent the learner from focusing on what is being taught.

Teach the patient wound care and infection control measures:
− − Keep incision clean and dry. If dressing is applied, change using aseptic technique. Monitor for signs of infection at incision site and drain insertion site: warmth, redness, purulent drainage, and increased pain. Monitor temperature for elevations.

- Due to the short hospital stay following cholecystectomy, the patient is at home when postoperative infections occur, so it is crucial that the patient know signs of infection, understanding the rationale for these interventions will enhance the patient’s willingness to comply with limitations.

IX. LIST OF PRIORITY OF PROBLEM

1. Ineffective breathing pattern related to pain on post operative site 2. Acute pain related to post operative incision secondary to laparoscopic cholecystectomy.

3. Impaired skin integrity related to surgical incision on abdomen secondary to laparoscopic cholecystectomy. 4. Impaired physical mobility related to pain at incision site

5. Deficient knowledge about self care activities r/t incision care, dietary modifications, medications reportable signs and symptoms

Legend: #1- being the highest priority #5- being the last priority