MEDICATIONS

DRUG
Inj. Cefriaxone SB

DOSAGE
1 gm

ROUTE
IV

FREQUENCY
Q8h

ACTION
rd

SIDE-EFFECTS

3 generation Superinfection, cephalosporin; anaphylaxis, Antibacterial diarrhea, local reactions, blood dyscrasis, rashes, pruritis. NSAID GI disturbances, headache, dizziness, rash, abnormality in kidney function, local irritation. Headache, dizziness, thrombocytopenia, leucopaenia, confusion, impotence, somnolence, vertigo. Dizziness, ARF, acute tubular necrosis, electrolyte imbalance, purpura, nausea, vomiting.

Inj. Divon (Diclofenac)

IV

Inj. Rantac

50 mg

IV

BD

H2-receptor antagonist

Inj. Amikacin

500 mg

IV

BD

Antibacterial

ASSESSMEST

NURSING DIAGNOSIS SUBJECTIVE Acute pain DATA related to I am feeling surgical severe pain on incision as the surgical manifested by site. complaints of OBJECTIVE pain, facial DATA grimacing, Restless, irritability, Irritability. decreased movement.

OBJECTIVES The client will experience reduced pain and become comfortable.

INTERVENTIONS 1.Assess the pain for character, location, and effectiveness of relief measures. 2. Assess the pain using numerical pain scale. 3. Give a comfortable position to the patient. 4. Use non pharmacological interventions such as distraction, relaxation, musical therapy etc.

RATIONALE

IMPLEMENTATIO EVALUATION N To plan Patient has pain on Patient says his appropriate the surgical wound. pain is reduced interventions. and become comfortable. To Patient has severe differentiate pain the type of pain. To promote Provided a relaxation. comfortable position with additional pillows. To reduce the Distract the attention pain by of the patient by diverting the conversation. attention of patient from pain.

5. Provide heat or Cold induce cold application. vasoconstrictio n, and hot increase circulation 6.Administer To reduce the Inj.Divon medications such as pain. (Diclofenac) analgesics as given prescribed .

BD

ASSESSMEST SUBJECTIVE DATA I feel weakness due to nil per oral. OBJECTIVE DATA Patient is on NPO since 3 days. Looks so weak.

NURSING DIAGNOSIS Altered nutrition less than body requirement related to NPO status as manifested by fatigue, weakness

OBJECTIVES

INTERVENTIONS

RATIONALE To plan care.

The client will 1. Assess dietary improve the habits, recent food nutritional habits. status. 2. Administer prescribed IV fluids such as DNS, RL etc.

IMPLEMENTATIO N the He takes mixed diet.

EVALUATION Nutritional status improved.

To meet the nutritional needs during postoperative period.

DNS; 5%D; RL and electrolytes are given according to the order.

3. Check for active To assess the bowel sounds. returning of GI function. Then start oral fluids. 4. Before the NG tube is removed, the patient is started on oral feedings of clear liquids.(30ml of fluid). Aspirate the tube after one hour. To determine the tolerance level. Aspirate for checking the retained fluid.

Bowel sounds are heard on 5th day. Then liquid diet started.

Oral fluids started before removal of NG tube. Good tolerance level.

5. When fluids are To start regular Rhyles tube nd well tolerated, the foods. removed on 22 . tube is removed and fluids are increased in frequency with a slow progression to regular foods

ASSESSMEST

NURSING DIAGNOSIS OBJECTIVE Risk for DATA infection Surgical wound related to is present. surgical incision, inadequate nutrition and fluid intake , invasive catheter and immobility.

OBJECTIVES

IMPLEMENTATIO EVALUATION N Patient will not 1.Monitor and report To determine Vital signs are Patient is not get any elevated possible normal. getting any infection temperature;invasive presence of infections. lines and catheters, infection. elevated pulse and respiration etc 2.Assess the surgical To determine Surgical wound is wound for redness, the infection. clean and healthy. swelling, warm area Amount of drainage surrounding incision is normal. and presence of purulent drainage from the wound. 3.Use strict aseptic technique in providing wound care, including hand washing and sterile dressing technique and emptying drainage devices. 4.Administer antibiotics. Inj.Ceftriaxone, Inj Amikacin. 5..Help patient turn, cough, and deep breath deeply every 1 to 2 hours while awake To prevent Sterile techniques wound followed. contamination.

INTERVENTIONS

RATIONALE

Prevent infection.

Inj.Ceftriaxone, Amikacin administered.

Inj

To prevent Not get respiratory respiratory infections. infections.

any

ASSESSMEST

NURSING DIAGNOSIS OBJECTIVE Risk for DATA injury: post Patient operative underwent complications vagotomy, a related to major bleeding, abdominal distention and surgery. atelectasis.

OBJECTIVES

INTERVENTIONS

RATIONALE To plan care

The client will 1.Assess for any not suffer from signs of any complications. complications. 2.Check vital signs every 30 mintes in immediate postoperative period. 3.Donot reposition the NG tube or gastrostomy tube after gastric surgery.

IMPLEMENTATIO EVALUATION N the Assessed signs of Patient has no complications. postoperative complications. are and

It is the first Vital signs signs for the checked complications. recorded.

It may be NG tube and drain is placed directly in proper position. over the suture line.

4.Assess color, For assessing Yellow green amount and odor of hemorrhage. colored drainage. the drainage. 5.Carefully measure For assessing Intake and output is and document intake the normal. and output including complications. the IV fluids and drainage. 6.Encourage early To prevent Early ambulation, deep atelectasis. started. breathing and coughing exercise. ambulation

ASSESSMEST

NURSING DIAGNOSIS SUBJECTIVE Sleep pattern DATA disturbance I can¶t able to related to sleep in night acute pain as due to pain. manifested by OBJECTIVE yawning and DATA patient Frequent statement. yawning and patient statement.

OBJECTIVES

INTERVENTIONS

RATIONALE

Patient will get 1. Ask the patient to adequate rest describe the usual and sleep. sleep environment; when possible, modify the patient¶s surroundings.

IMPLEMENTATIO EVALUATION N An unfamiliar Usually he sleeps Patients¶ sleep environment around 6 hours. improved. may inhibit sleep.

2. Avoid performing To prevent Painful procedures prolonged or painful sleep are avoided. procedures within interference. the hour before bedtime. 3. prescribed analgesics sedatives. Provide Reduce pain Inj. Divon sensation and (Diclofenac) given. or induce sleep.

4. Allow the patient Help patient to Encouraged to follow rituals that fall asleep. follow rituals. promote sleep at home. 5. Reposition the patient for comfort, and offer smoothening back rub. Due the bed Repositioned rest immobility client. can increase discomfort.

to

the

ASSESSMEST

NURSING DIAGNOSIS OBJECTIVE Knowledge DATA: deficit Patient regarding post repeatedly asks operative and about home care as management. manifested by repeated questions regarding therapies.

OBJECTIVES

IMPLEMENTATIO N Patient and 1. Assess the To plan the Assessed the family acquire knowledge level of education knowledge of patient adequate the patient and programme. and family. knowledge family. regarding treatments. 2. Explain dietary To prevent Explained about modifications, complications. dietary modification. including avoidance of foods that cause epigastric distress. 3. Avoid cigarettes Smoking will Explained about smoking and alcohol delay healing. importance of intake. avoidance of bad habits. 4. To take all Prevent Explained about medications as complications. medications. prescribed. 5. Explain the Increased Explained relaxation relationship between stress is a risk techniques. symptoms and factor for PUD stress. Stressreducing activities or relaxation strategies are encouraged. 6.Explain about Follow up is Explained follow up. follow up care. necessary.

INTERVENTIONS

RATIONALE

EVALUATION Patient and family acquire adequate knowledge regarding treatments.