NCP

HI I AM ARIANE DURAN AND I WILL BE PRESNTING THE NURSING CARE PLA

THE PRIORITY NURSING CARE PLAN FOR THE PRE OP HAVE THE FOLLOWING ASSESSMENT WHEREIN FOR
THE

SUBJECTIVE DATA: The patient verbalized “sobrang sakit po ng tyan ko lalo na po dito (pointing at the
right upper quadrant of the abdomen) ”

FOLLOWED BY THE OBJECTIVE DATA: WHICH YUNG PATIENT NAMIN LOOKS

- Pale -Restless -Grimace -Can’t stand and walk properly

- swollen and tender abdomen -pain scale of 7/10 Vital Signs T: 38.6 ̊ C PR: 90 BPM
RR: 23 CPM BP: 90/60 mmHg Oxygen saturation 90 %

BASED ON THE ASSESSMENT WE CAME UP WITH THE NURSING DIAGNOSIS

Acute pain r/t inflammatory process of the pancreas AEB tender abdomen and a pain scale of 7/10

FOR THE SCIENTIFIC EXPLANATION

Since our patient was diagnosed WITH acute pancreatitis the cause( Causative Factors ) is
stones in gallbladder or the gallstones NG PATIENT and yung pagiging alcoholic ng patient
naming wherein base sa nabasa ko pong journal alcohol consumption causes 17% to 25% of acute
pancreatitis cases worldwide and is the second most common cause of AP after gallstones.

Due to excessive consumption of alcohol , THE process of acute pancreatitis is caused by

premature activation and release of pancreatic enzyme

Resulting in

Auto digestion of the pancreases which it is a process whereby pancreatic enzymes destroy its
own tissue leading to
inflammation of the pancreas

KAYA nakakaramdam na yung patient ng

Abdominal pain usually AN upper abdominal pain that radiates yung back ng patient.
ON THIS DIAGNOSIS, PLANNING WAS DONE WHEREIN FOR THE
SHORT TERM OBJECTIVE:
After 2-3 hours of nursing intervention the patient will be able to:

- Report a lower pain scale of 4/10 from 7/10

- Follow prescribed therapeutic regimen

- Demonstrate use of methods that provide relief

 
LONGTERM OBJECTIVE:
After 3 days of nursing intervention, the patient will be able to report pain relief or controlled.
SO WE HAVE HERE THE NURSING INTERVENTIONS FOR THE INDEPENDENT
1. Assessed pain level at baseline, before and after administration of analgesic
medications.
Using an appropriate pain rating scale will help to monitor the level of pain and adjust
pain medications as needed.
2. Maintained bedrest during acute attack and provide quiet, restful environment.

It decreases stimulation of pancreatic secretions

ACCORDING PO SA PUB MED, majority of patients with acute gallstone pancreatitis have mild
disease and recover within 3 to 5 days with bed rest and intravenous fluid replacement.

3. Promoted a position of comfort, such as on one side with knees flexed or sitting
up and leaning forward.

Reduces abdominal pressure and tension, providing some measure of comfort and pain
relief.

ACCORDING SA AMERICAM FAMILY JOURNAL Patients WITH PANCREATITISI are usually

restless and bend forward (the knee-chest position) iS an effort to relieve the pain, tas NABASA
KO PO DOON NA IYUNG supine position may exacerbate the intensity of symptoms NG PAIN.

4. Used nonpharmacological interventions for relieving pain such as BACK RUB

relaxation, LIKED DEEP BREATHING EXERCISES AND diversional ACTIVITIES
SUCH AS LISTENING TO MUSIC, WATCHING TV

The use of nonpharmacological method will enhance the effects of analgesic

medications. ENABLES PATIENT TO REFOCUS ATTENTION

5. Kept the environment free of food odors.

Sensory stimulation can activate pancreatic enzymes. 

6. . Listened to patient’s expression of pain experience.

Demonstration of caring can help decrease anxiety.

DEPENDENT

7. . Maintained the patient NPO

Limits and reduces release of pancreatic enzymes and resultant pain.

8. Administered acetaminophen frequently as prescribed to achieve level of pain

acceptable to patient

Acetaminophen is a pain reliever and a fever reducer. It is used to treat mild to moderate

and pain.
AFTER FOLLOWING ALL THE NURSING INTERVENTIONS
GOAL MET, ON BOTH STO AND LTO WHEREIN FOR
SHORT TERM OBJECTIVE:
After 2-3 hours of nursing intervention the patient was able to

- Reported a lower pain scale of 3/10

- Followed prescribed therapeutic regimen such as taking analgesic medications.

- Demonstrate method of relief such as proper positioning and breathing exercise.

LONG TERM OBJECTIVE:

After 3 days of nursing intervention, the patient was able to relieved pain AEB absence of
grimace, symmetric abdomen, moves and turns without increasing pain.

THE NEXT NCP IS WITH THE FOLLOWING ASSESSMENT

SUBJECTIVE DATA:
The patient verbalized “Nahihirapan po akong huminga at kinakapos po ako sa paghinga ”
OBJECTIVE DATA:

- Dyspnea -Restless -Anxious -Oxygen in use via high flow nasal cannula, with a flow
rate of 60L per minute -Bubbling breath sound -Crackles Lung sound -rapid rise
and fall of the chest -bluish nails and lips
Vital Signs- T: 38.6 ̊ C PR: 90 BPM RR: 23 CPM
BP: 90/60 mmHg Oxygen saturation 90%
THAT CAME UP WITH THE DIAGNOSIS OF
Ineffective breathing pattern r/t hyperventilation secondary to ARDS AEB shortness of
breath
THE DIAGNOSIS EXPLAINED THAT

IN Acute pancreatitis, IT
Is a serious and at times life threatening inflammatory process of the pancreas which these
acute pancreatitis can affect the respiratory system through a lot inflammatory chemicals that
is are secreted into the bloodstream ( Bloodstream filled with inflammatory chemicals )which
these chemicals created inflammation including the lungs which can lead into an
Inflamed lungs , including alveoli in which can results difficulty for oxygen to pass through the
alveoli into the bloodstream.
Because of this sthe vessels in lungs constrict and can cause increased pressure that will now
lead to
Deprived lung function WHICH LEADS TO ACUTE RESPIRATORY SYNDROME, BECAUSE THE
USUAL EXCHANGE BET O2 AND CO2 IN THE LUNGS DOES NOT OCCUR, WHICH ENOUGH
PXYGEN CANNOT REACH THE HEART, BRAIN OR THE REST OF THE BODY, SO THE PATIENT CAN
NOW FEEL
Shortness of breath and rapid breathing which can lead to
Ineffective breathing pattern
FOR THE PLANNING ON
SHORT TERM OBJECTIVE:
After 2-3 hours of nursing intervention the patient will be able to:
- Establish a normal and effective respiratory pattern with a T: 38.6 to 36.5, PR: 90 bpm
to 75 bpm, RR: 23 cpm to 19 cpm and oxygen saturation of 90% to 95%
- Participate in treatment regimen
 
LONGTERM OBJECTIVE:
After 3 days of nursing intervention, the patient will be able to exhibit reduce signs and
symptoms of respiratory infection.

SO WE HAVE HERE THE NURSING INTERVENTIONS FIRST ID FOR THE INDEPE INTER
1. Assessed respiratory rate and depth.
 Respiratory rate and rhythm changes are early warning signs of impending respiratory
difficulties.
2. Auscultated and percussed chest, described presence, absence and character of
breath sounds.
Abnormal breath sound is indicative of numerous problems and must be evaluated
further.

3. Observed chest size, shape and symmetry of movement.

Changes of movement in chest wall can impair breathing patterns.

4. Maintained semi-Fowler position

Decreases pressure on diaphragm and allows greater lung expansion.
ACCORDING SA READINGS KO An upright position allows for a better lung expansion, hence more air
reaching the lungs for gas exchange. 

5. Assisted patient to turn and change position every 2 hours.

. Changing position frequently assist aeration and drainage of all lobes of the lungs.

6. Elevated the head of the bed and have the client sit up in a chair
To promote physiological and psychological ease of maximal inspiration

7. Instructed and encouraged the patient to take deep breaths and to cough every hour.

Taking deep breaths and coughing will clear the airways and reduce atelectasis.
ACCORDING PO SA UCHEALTH ORGANIZATION, Deep breaths are more efficient: they allow your body to
fully exchange incoming oxygen with outgoing carbon dioxide. They have also been shown to slow the
heartbeat, lower or stabilize blood pressure and lower stress.

8. Pace and schedule activities providing adequate rest periods.

This prevents dyspnea resulting from fatigue.

DEPENDENT
9. Introduced oxygen via High flow nasal cannula (HFNC) with a flow rate of 60 liters per
minute
 A high-flow nasal cannula accomplishes a reduction of nasopharyngeal airway resistance,
leading to improved ventilation and oxygenation through the application of a positive
pressure environment.
EVALUATION
GOAL MET,
SHORT TERM OBJECTIVE:
After 2-3 hours of nursing intervention the patient was able to
- Established a normal and effective respiratory pattern AEB, T: 36.5, PR: 75bpm, RR:
19cpm and Oxygen saturation: 95 %
- Participated in treatment regimen such as breathing exercise
LONG TERM OBJECTIVE:
After 3 days of nursing intervention, the patient was able to reduce signs and symptoms of
respiratory infection AEB equal rise and fall of the chest and normal skin color

THEN THE NEXT NCP IS EVEIDENCED BY THE ASSESSMENT FOR THE

SUBJECTIVE DATA WHICH
The patient verbalized “nanghihina ako at kaylangan pa akong alalayan ng aking asawa kapag
ako ay kakain , tatayo o maglalakad ”
OBJECTIVE DATA:
- Slow movement -Need assistance upon changing position -Dyspnea -Pale
-Patient is in bed rest
- Can’t stand and walk well -performs limited personal care independently
Vital Signs: T: 38.6 ̊ C PR: 90 BPM RR: 23 CPM BP: 90/60 mmHg - oxygen saturation
90%
THE NURSING DIAGNOSIS FOR THIS IS
Activity intolerance r/t low oxygen level AEB body weakness
Hypoxemia occurs when levels of oxygen in the blood is lower than normal wherein our patient
has a 90% saturation, since yung patient naming is mababa yung oxygen level,
Patient may feel tired wherein Fatigue comes more quickly when the lungs can't properly inhale
and exhale air which can lead to
Body weakness
Due to this there will be the
Difficulty in moving
Including the Decreased movement of the patient and need an assistance in performing some
activities that can lead to
Activity intolerance
PLANNING WAS DONE WHEREIN, FOR THE SHORT TERM OBJECTIVE:
After 2-3 hours of nursing intervention the patient will be able to:
- Demonstrate a decrease in physiologic signs of intolerance such as PR: 90 bpm to 75
bpm , RR: 23 cpm to 19 cpm, BP: 90/60 mmHg to 120/80 mmHg and oxygen saturation
of 90% to 95%
- Demonstrate an increase in activity level
LONGTERM OBJECTIVE:
- After 3 days of nursing intervention, the patient will be able to increase and achieve
desired activity level with no intolerance symptoms.
THE FOLLOWING ARE THE NURSING INTERVENTIONS FOR THE
INDEPENDENT
1. Monitored heart rate, rhythm, respirations and blood pressure for abnormalities.
Changes in VS assist in monitoring physiologic responses to increase in activity.

2. Assessed laboratory results.

Data will help for the progress of interventions as well as it will determine extent of
severity of condition.

3.  Drink lots of fluid

When drinking lots of water, the lungs remain properly hydrated, which improves their
ability to oxygenate and expel carbon dioxide. Therefore, the oxygen saturation level of
the body gets improved
4. Placed patient in an upright position several times per day
 Upright positioning helps prevent the deconditioning of the heart and lungs. Lying for a
prolonged period may contribute to decreased cardiac output, increased resting heart
rate, and orthostatic hypotension.

5. Include more antioxidants in your diet such as strawberries, blackberries, kidney

beans, and plums
Antioxidants allow your body to use oxygen more efficiently, thereby helping your
blood's oxygen saturation level
6. Assessed muscle strength  
Muscle strength may suggest the extent of weakness of patient
7. Practiced slow and deep breathing
Breathing pattern can have a vast effect on the blood's oxygen saturation level. By
changing the breathing style, it can provide a significant boost to the blood’s SpO2 level.
THE BOTH STO AND LTO
GOAL MET,
SHORT TERM OBJECTIVE:
After 2-3 hours of nursing intervention the patient was able to
- Demonstrated a normal range of physiologic signs of intolerance AEB, PR: 75bpm, RR:
19cpm and BP: 120/80 mmHg and Oxygen saturation of 95%
- Demonstrated an increase in activity level AEB patient can perform limited activity
without the assistance of his wife.
 
LONG TERM OBJECTIVE:
After 3 days of nursing intervention, the patient was able to increase and achieved desired
activity level AEB normal movement, can walk, stand and perform all activity without the
assistance of his wife

FOR THE 4TH NCP WE HAVE HERE THE FF ASSESSMENT

SUBJECTIVE DATA:
The patient verbalized “ nahihirapan ako makatulog sa gabi dahil iniisip ko itong kalagayan
ko”
“kaylangan ko pang uminum ng alak para lang makatulog”
OBJECTIVE DATA:
- Restlessness -Pale -Dark circles under the eyes
- Yawning Vital Signs- T: 38.6 ̊ C PR: 90 BPM
RR: 23 CPM BP: 90/60 mmHg Oxygen saturation : 90 %
WHICH CAME UP WITH THE DIAGNOSIS OF
Disturbed sleeping pattern r/t anxiety AEB 5 hours of sleep
THE SCIENTIFIC EXPLANATION
Current medical condition , SINCE OUR PATIENT IS PREPARING FOR A SURGERY THERE IS THE
FEELING
OF UNEASINESS OR WORRY FOR THE PATIENT (Anxiety),
WHEREIN CONNECTIONS HAVE BEEN FOUND BETWEEN ANXIETY DISOREDERS AND CHANGES
IN A PERSON’S SLEEP CYCLES AND INDICATES THAT IT MAY AFFECT THE REM OR THE RAPID
EYE MOVEMENT SLEEP THAT CAN LEADS TO A SLEEPING PROBLEMS OR THERE IS THE
Disturbance of sleep , WITH THIS , IT MAY AFFECT THE MOOD AND EMOTIONAL HEALTH OF A
PERSON SUCH AS FEELING OF
Restlessness
SO WE HAVE HERE THE PLANNING
SHORT TERM OBJECTIVE:
After 2-3 hours of nursing intervention the patient will be able to:
- Verbalize understanding the importance of sleep
- Identify ways how to improve sleeping pattern
LONGTERM OBJECTIVE:
After 3 days of nursing intervention, the patient will be able to achieve optimal amount of
sleep

FOR THE NURSING INTERVENTION THE INDEPENDENT ARE THE FOLLOWING

INDEPENDENT:
1. Assessed patient’s sleep pattern, naps, amount of activity and patients’ complaints of
lack of rest,
Provide information to alleviate sleep deprivation in relation to age related changes and
identity.

2. Provided calm, quiet environment, closing curtains and adjusting lighting.

Helps to promote conducive atmosphere for restful sleep.

STUDIES HAVE SHOWN PEOPLE CAN SLEEP BETTER WHEN THEIR ROOM IS OPTIMIZED FOR LIGT
AND NOISE LEVELS, TEMPERATURE AND COMFORT.

3. Instructed patient to avoid stimulants like caffeine drinks and stressful activity
Overstimulation prevents patient from falling asleep.
CAFFEINE BLOCKS THE ADENOSINE RECEPTOR TO KEEP FROM FEELING SLEEPY. ONE
STUDY ALSO FOUND OUT THAT CAFFEINE CAN DELAY THE TIMING OF THE BODY CLOCK
WHICH REDUCE THE TOTAL SLEEP TIME. IN TERMS OF STRESSFUL ACTIVITY, ACCORDING
TO A STUDY ONE EFFECT OF STRESS IS THAT IT CAN CAUSE SLEEP DEPRIVATION WHICH
SA CASE NG PATIENT NAMIN IS SOBRANG NAG AALALA SIYA SA CONDITION AND
UPCOMING ZSURGERY LEADING HIM NOT FEEL SLEEPY.

4. Provided accurate information about his situation.

Helps the client to identify what is reality based

5. Provided warm drinks, extra cover, warm bath prior to bedtime.  

Promote comfort and relaxation prior to sleep.

6. Encouraged the patient to talk about his feelings on his condition.

 Verbalization of feelings in a nonthreatening environment may help client to terms with
unresolved issues.

7. . Instructed the patient to avoid alcohol prior to bedtime.

Although alcohol may cause sleepiness, it interrupts sleep later in the night.

8. Used simple language and brief statements when instructing the patient about self-
care measures or about diagnostic and surgical procedures.
When experiencing anxiety, patient may be unable comprehend properly more than
simple and brief instructions. 

DEPENDENT:
9. Administered medication such as hypnotics to promote normal sleep patterns as
ordered
Medications may be required to achieve rest during hospitalization. Hypnotics induce
sleep, while tranquilizers reduce anxiety
AT THE END OF THE INTERVENTION
GOAL WAS MET,
SHORT TERM OBJECTIVE:
After 2-3 hours of nursing intervention the patient was able to
- Verbalized understanding the importance of sleep AEB “nakakatulog na ako ng maayos kahit
hindi umiinum ng alak gabi gabi”
- Identified ways how to improve sleeping pattern such avoid drinking alcohol and caffeine
before going to sleep.
 
LONG TERM OBJECTIVE:
After 3 days of nursing intervention, the patient was able to achieve optimal amount of sleep
AEB rested appearance and a number of 7-8 hours of sleep pattern.
THE LAST NCP IS FOR THE POST OP , IT IS EVIDENCED OF THE FF ASSESSMENT
SUBJECTIVE DATA:
The patient verbalized “ Inoperahan ako gamit ang whipple procedure para sa sakit kong
pancreatitis”
 
OBJECTIVE DATA:
- Weak in appearance -Febrile -Incision on the abdomen
- Grimace -Clean and intact abdominal dressing
Vital Signs
T: 38.6 ̊ C
PR: 90 BPM
RR: 23 CPM
BP: 90/60 mmHg
WITH THESE ASSESMENT IT CAME UP WITH THE DIAGNOSIS OF
Risk for infection r/t surgical incision AEB Whipple Procedure
FOR THE SCIENTIFIC EXPLANATION
SINCE OUR PATIENT UNDERWENT A SURGERY WHICH IS

Whipple Procedure  also known as a pancreaticoduodenectomy — is a complex

operation to remove the head of the pancreas, the first part of the small intestine
(duodenum), the gallbladder and the bile duct.The Whipple procedure is used to treat
tumors and other disorders of the pancreas, intestine and bile duct.

IN THIS PROCEDURE The surgeon makes an incision in THE abdomen OF THE PATIENT to
access THE internal organs.WHICH DITO SA PROCEDURE NA TO, the head of the pancreas,
the beginning of the small intestine (duodenum), the gallbladder and the bile duct are removed.
Incision
SINCE THERE IS THE INCISION THERE WILL BE NOW A Trauma on skin THEN THERE
WILL ASLO THE
Broken Skin WHEREIN BACTERIA OR OTHE MICROORGANISMS CAN ENTER
ESPECIALLY IF THE WOUND IS NOT A CLEAN AND HAVE PROPER DRESSING, IN THIS
CASE KAPAG DI NALILINISAN NG MAAYOS YUNG INCISION SITE PWEDE NA MAG LEAD
SA
Risk for Infection

WE CAME UP WITH PLANNING OF

SHORT TERM OBJECTIVE:
After 2 hours of nursing intervention the patient will be able to:
- Identify risk factors that are present
- Participate in activities to reduce risk of infection.
 
 
LONGTERM OBJECTIVE:
At the end of hospitalization, the patient will be free from any signs and symptoms of infection.  

WE HAVE HERE THE NURSING INTERVENTIONS

INDEPENDENT:
1. Assessed signs of infection such as temperature.
Fever is often the first sign of an infection. A temperature of up to 38º C ,48 hours post-
op is usually related to surgical stress after 48 hours. A temperature of greater than
37.7º may indicate infection.

A very high temperature accompanied by sweating and chills may

indicate septicemia.

2. Maintained strict asepsis for dressing changes, wound care, intravenous therapy

and catheter handling.
Aseptic technique decreases the chances of transmitting or spreading pathogens to or
between patients. Interrupting the chain of infection is an effective way to prevent the
spread of infection.

ETO IS INISTRUCT DIN NAMIN SIYA SA SIGNIFICANT OTHERS TO know the

instances when to perform hand hygiene or “5 moments for hand hygiene”:
Before touching THE patient.
Before clean or aseptic procedure (wound dressing, starting an IV, etc.).
After body fluid exposure risk
After touching a patient
After touching the patient’s surroundings.

3. Washed hands or performed hand hygiene before having contact with the patient. 
Reduce risk of cross-contamination
4. Encouraged intake of protein-rich and calorie-rich foods and encourage a
balanced diet.
Proper nutrition and a balanced diet support the immune systems’ responsiveness and
enhance the health of all the body’s tissues.

 Adequate nutrition enables the body to maintain and rebuild tissues and helps
keep the immune system functioning well.

5. . Kept the client and SO’s fingernails short and clean.

Rough edges or hangnails can harbor microorganisms.

6. Encouraged sleep and rest.

Adequate sleep is an essential modulator of immune responses. A lack of sleep can
weaken immunity and increased susceptibility to infection

DEPENDENT:
7. Administered antibiotics such as ceftriaxone
Ceftriaxone is used for the treatment of the infections caused by susceptible organisms.
AFTER ALL THE NURSING INTERVENTIONS
GOAL MET,
SHORT TERM OBJECTIVE:
After 2 hours of nursing intervention the patient was able to
- Identified risk factors that are present AEB surgery for 6 hours.
- Participated in activities to reduce risk of infection such as performing hand hygiene and
maintaining aseptic technique
 
LONG TERM OBJECTIVE:
At the end of hospitalization, the patient was free from any signs and symptoms of infection
AEB normal temperature of 36.5