NURSING CARE PLAN

ASSESSMENT
Subjective: Masakit ang opera ko as verbalized by the patient. Objective: Facial mask of pain. Limited range of motion. Disruption of skin. V/S taken as follows: T: 37.2 P: 90 R: 19 BP: 110/80

DIAGNOSIS
Impaired tissue integrity related to presence of secretions.

INFERENCE Cholecystect omy is the surgical removal of the gallbladder, which is located in the abdomen beneath the right side of the liver. Gallbladder problems are usually the result of gallstones. These stones may block the flow of bile from your gallbladder, causing the organ to swell. Other causes include cholecystitis (inflammatio n of the gallbladder)

PLANNING
After 3 days of nursing interventions, the patient will achieve timely wound healing without complications.

INTERVENTION
Independent: Change dressings as often as needed and use karaya powder around the incision.

RATIONALE
Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation. Ostomy appliance may be used to collect heavy drainage for accurate measurement of output and protection of the skin. To facilitates drainage of bile. Developing jaundice may indicate obstruction of the bile flow. Clay colored stools result when bile is not present in the intestine. Signs suggestive of abcess of fistula formation, requiring medical

EVALUATION
After 3 days of nursing interventions, the patient was able to achieve timely wound healing without complications.

Use disposable ostomy bag over a stab wound drain.

Place patient in low or semifowlers position. Observe for skin, sclerae, urine for change of color.

Note color and consistency of stools.

Investigate reports of increased right upper quadrant pain, development of

and cholangitis (inflammatio n of the bile duct).

fever, tachycardia. Collaborative: Administer antibiotics as prescribed. Monitor laboratory studies like white blood cells.

intervention.

Necessary for treatment of abscess or infection. Leukocytosis reflects inflammatory process.