NURSING

CUES/NEEDS SCIENTIFIC BASIS OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Acute Pain r/t Cholelithiasis General: Goal met as
"Masakit pagad biological l After 2 days of evidenced by
it ak tiyan ha injuring Further complication holistic student relieved
may tuo dapit agents: l nurse-patient expression of
pero dire na obstruction/ Inflammation of the interaction, the patient. Patient
gud duro", as ductal spasm, gallbladder patient will achieve is able to
verbalized by inflammatory l her optimum level of tolerate the
the patient. process as Acute cholecytitis functioning. pain; pain scale
evidenced by l of 1.
OBJECTIVE: reports of Disrupting Specific:
 Behavioral pain and movement & After 6-8 hours of
changes: guarding of distortion of tissuesholistic intervention,
Restlessness site l the patient/SO will
& Irritability Activation of be able to:
 Pain scale: 2; nociceptors in the 1. Report pain is
mild; Hurts dermis and tissues relieved/controlle INDEPENDENT
little bit l d. 1. Observe and document 1. Assists in differentiating
 v/s taken as Receptors send 2. Demonstrate use location, severity (0–10 cause of pain, and
follows: impulses to CNS for of relaxation skills scale), and character of provides information
o T: 36.7 °C interpretation and diversional pain (steady, about disease
o P: 101 bpm l activities as intermittent, colicky). progression and
o R: 21 cpm Pain perception indicated for resolution, development
o BP: 110/70 l individual of complications, and
mmHg Acute pain situation. effectiveness of
3. Maintain a 2. Note response to interventions.
relieved state for medication, and report to 2. Severe pain not relieved
the time being. physician if pain is not by routine measures may
Source: being relieved. indicate developing
https://nurseslabs.co complications or need for
m/4-cholecystitis- 3. Promote bedrest, further intervention.
cholelithiasis- allowing patient to 3. Bedrest in low-Fowler’s
nursing-care-plans/ assume position of position reduces intra-
 comfort.
4. Control environmental
temperature.
5. Encourage use of
relaxation techniques.
Provide diversional
activities.
6. Make time to listen to
and maintain frequent
contact with patient.
7. Keep side rails up.
8. Check for things that
triggers the pain to
worsen.
COLLABORATIVE:
9. Administer antibiotics, as
ordered.
10. Administer anti-
inflammatory, as
prescribed.
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cholecystitis-cholelithiasis-
nursing-care-plans/
abdominal pressure;
however, patient will
naturally assume least
painful position.
4. Cool surroundings aid in
minimizing dermal
discomfort.
5. Promotes rest, redirects
attention, may enhance
coping.
6. Helpful in alleviating
anxiety and refocusing
attention, which can
relieve pain.
7. For safety of patient.
8. To alleviate pain.
9. To treat infectious
process, reducing
inflammation
10. To reduce inflammation.
CUES/NEEDS NURSING SCIENTIFIC BASIS OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE: Risk for Cholelithiasis General: Goal met as
"Makadamo ak Deficient l After 2 days of evidenced by
babalik ha C.R. Fluid Further holistic student relieved
kay sige-sige Volume complication nurse-patient expression of
ak ihi", as l interaction, the patient.
verbalized by Inflammation of the patient will achieve Patient is able
the patient. gallbladder her optimum level of to tolerate the
l functioning. pain; pain
OBJECTIVE: Acute cholecytitis scale of 1.
 Behavioral l Specific:
changes: Disrupting After 6-8 hours of
Restlessness movement & holistic intervention,
& Irritability distortion of tissues the patient/SO will
 Urine output: l be able to: INDEPENDENT
6 Excessive losses 1. Verbalizes 1. Maintain accurate 1. To provide information
 v/s taken as through distension, knowledge on record of I&O, noting about fluid status and
follows: and gastric how to hydrate output less than intake, circulating volume
o T: 36.7 °C hypermotility self. increased urine specific needing replacement.
o P: 101 bpm 2. Demonstrate gravity.
o R: 21 cpm adequate fluid 2. Assess skin and 2. To provide information
o BP: 110/70 balance mucous membranes, about fluid status and
mmHg evidenced by peripheral pulses, and circulating volume
stable vital signs, capillary refill. needing replacement.
moist mucous 3. Monitor for signs and 3. Prolonged vomiting,
membranes, symptoms of increased gastric aspiration, and
Source: good skin turgor, or continued nausea or restricted oral intake
https://nurseslabs.c capillary refill, vomiting. can lead to deficits in
om/4-cholecystitis- individually sodium, potassium,
cholelithiasis- appropriate and chloride.
nursing-care-plans/ urinary output, 4. Eliminate noxious 4. Reduces stimulation of
 absence of sights or smells from vomiting center.
vomiting. environment.
3. Maintain a well 5. Perform frequent oral 5. Decreases dryness of
state of a hygiene with alcohol- oral mucous
hydrated self. free mouthwash; apply membranes; reduces
lubricants. risk of oral bleeding.
6. Use small-gauge 6. Reduces trauma, risk
needles for injections of bleeding or
and apply firm pressure hematoma formation.
for longer than usual
after venipuncture.
7. Assess for unusual 7. Prothrombin is reduced
bleeding: oozing from and coagulation time
injection sites, prolonged when bile
epistaxis, bleeding flow is obstructed,
gums, ecchymosis, increasing risk of
petechiae, bleeding or
hematemesis or hemorrhage.
melena.
8. Keep patient NPO as 8. Decreases GI
necessary. secretions and motility.
9. Encourage pt to 9. Decreases dryness of
increase fluid intake. oral mucous
membranes; reduces
risk of oral bleeding.
COLLABORATIVE:
10. Insert NG tube, connect 10. Decreases GI
to suction, and maintain secretions and motility.
patency as indicated.

Source:
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CUES/NEEDS NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS INTERVENTION
SUBJECTIVE: Deficient Deficient General: Goal met as
"Kasabot gad Knowledge r/t Knowledge: After 2 days of evidenced by
ak kun ano it unfamiliarity Absence or holistic student relieved
meaning it ak with deficiency of nurse-patient expression of
sakit pero di ak information cognitive interaction, the patient.
maaram kun resources as information patient will achieve Patient is able
asa dapit ang evidenced by related to specific her optimum level of to tolerate the
tanggalon ht raising of topic. functioning. pain; pain
surgery", as questions; scale of 1.
verbalized by request for A lack of cognitive Specific:
the patient. information information or After 6-8 hours of
psychomotor holistic intervention,
OBJECTIVE: ability needed for the patient/SO will
 Behavioral health restoration, be able to: INDEPENDENT
changes: preservation, or 1. Verbalizes 1. Explain reasons for test 1. Information can
Raising of health promotion understanding of procedures and decrease anxiety,
questions is identified as disease process, preparations as thereby reducing
 I&O: Knowledge Deficit prognosis, needed. sympathetic
o U: 6 or Deficient potential stimulation.
o S: 1 Knowledge. complications.. 2. Review disease 2. Provides knowledge
 v/s taken as Knowledge plays 2. Demonstrate process and prognosis. base from which
follows: an influential and necessary patient can make
o T: 36.7 °C significant part of lifestyle changes informed choices.
o P: 101 bpm a patient’s life and and participate in 3. Discuss hospitalization 3. Effective
o R: 21 cpm recovery. It may treatment and prospective communication and
o BP: 110/70 include any of the regimen. treatment as indicated. support at this time can
mmHg three domains: 3. Maintain a diminish anxiety and
cognitive domain positive outlook promote healing.
(intellectual of her condition to 4. Encourage questions, 4. Effective
activities, be able to assist expression of concern. communication and
problem-solving, her well-being. support at this time can
and others); diminish anxiety and
affective domain promote healing
(feelings, 5. Review drug regimen, 5. Gallstones often recur,
attitudes, belief); possible side effects. necessitating long-term
and psychomotor therapy. Development
domain (physical of diarrhea or cramps
skills or during chenodiol
procedures). It is therapy may be dose-
the duty of the related or correctable.
nurse to Note: Women of
determine with childbearing age
the patient what should be counseled
to teach, when to regarding birth control
teach, and how to to prevent pregnancy
teach certain and risk of fetal hepatic
matters and damage.
concerns on 6. Discuss weight 6. Obesity is a risk factor
health. Adult reduction programs if associated with
learning principles indicated. cholecystitis, and
guide the weight loss is beneficial
teaching-learning in medical
process. management of chronic
condition.
Physicians have 7. Instruct patient to avoid 7. Limits or prevents
an important role food/fluids high in fats recurrence of
in patient (pork, gravies, nuts, gallbladder attacks..
education. fried foods, butter,
However, whole milk, ice cream),
physicians are not gas producers
alone in (cabbage, beans,
education onions, carbonated
patients. This is beverages), or gastric
where nurses get irritants ( spicy foods,
in the manner of caffeine, citrus). Assess
offering patient for unusual bleeding:
education as a oozing from injection
way of providing sites, epistaxis,
nursing care to bleeding gums,
obtain the best ecchymosis, petechiae,
outcomes for their hematemesis or
patients. Patient melena.
education should 8. Review signs and 8. Indicative of
always be made symptoms requiring progression of disease
available in the medical intervention: process and
healthcare recurrent fever; development of
setting. A patient persistent nausea and complications requiring
is considered vomiting, or pain; further intervention.
most effective jaundice of skin or
when information eyes, itching; dark
is accessible urine; clay-colored
whenever it is stools; blood in urine,
needed. stools, vomitus; or
bleeding from mucous
According to membranes.
Dorothea Orem’s 9. Recommend resting in 9. Promotes flow of bile
Self-Care Theory, semi-Fowler’s position and general relaxation
the goal of after meals. during initial digestive
nursing was to process.
render the patient 10. Suggest patient limit 10. Promotes gas
capable of gum chewing, sucking formation, which can
meeting self-care on straw and hard increase gastric
needs, a process candy, or smoking. distension and
that often discomfort.
includes patient Source: Source:
teaching. Yet, https://nurseslabs.com/4- https://nurseslabs.com/4-
many factors cholecystitis-cholelithiasis- cholecystitis-cholelithiasis-
influence patient nursing-care-plans/ nursing-care-plans/
education,
including age,
cognitive level,
developmental
stage, physical
limitations, the
primary disease
process and
comorbidities,
and sociocultural
factors. Certain
ethnic and
religious groups
hold unique
beliefs and health
practices that
must be
considered when
designing a
teaching plan.

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