NURSING CARE PLAN

1. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy. 2. Impaired skin integrity related to surgical procedure: laparoscopic cholecystectomy secondary to calculous cholecystitis 3. Risk for infection related to presence of surgical incision.

NURSING CARE PLAN 1. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy. Assessment Subjective: Masaki ang opera ko as verbalized by the patient Nursing Diagnosis Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy as evidenced by pain scale of 8/10. ( Pain is a common aftermath for every surgery after the anesthesia wore down. Pain is recognized in two different forms: physiologic pain and clinical pain. Physiologic pain comes and goes, and is the result of experiencing a high>Position the patient properly in bed. Elevate head of bed. Maintain anatomic alignment. Alignment helps prevent pain from malposition and it enhances comfort Planning At the end of 3 hours nursing intervention, the patient will be able to report a decrease in Nursing Interventions > Monitor and assess vital signs every 2 hours because vital signs are usually altered in acute pain >Instruct and demonstrate to the patient the use of deep breathing exercise. Also instruct patient to do splinting while doing deep breathing Evaluation At the end of rendering 3 hours nursing intervention, the patient was able to report pain as relieved and controlled.

Objective: pain scale of 8 out of 10 facial grimaced Guarding behavior at the incision sites Slow and limited movement of the upper extremities 0.5 mm incision on the right lower rib cage and the subxyphoid

pain intensity to exercises. Deep breathing increases a scale of 3 out of 10. oxygen in the body and prevents atelectasis. Deep breathing exercise also provides comfort.Splinting while doing deep breathing is to lessen the pain upon respiration.

area; 10mm incision below the umbilicus. Incisions are covered with dry and intact dressing. Vital Signs: T- 36.6C; BP- 130/90; RR-18; PR- 81.

intensity sensation. It often acts as a safety mechanism to warn individuals of danger (e.g., a burn, animal scratch, or broken glass). Clinical pain, in contrast, is marked by hypersensitivity to painful stimuli around a localized site, and also is felt in non-injured areas nearby. When a patient undergoes surgery, tissues and nerve endings are traumatized, resulting in incision pain. This trauma overloads the pain receptors that send messages to the spinal cord, which becomes overstimulated. The resultant central

>Encourage diversional activities (TV/radio, socialization with others, mental imaging). These highten ones
concentration upon nonpainful stimuli to decrease one's awareness and experience of pain.

>Provide rest periods to facilitate comfort, sleep, and relaxation. The patient's experiences of pain may become exaggerated as the result of fatigue. Adequate rest helps provide comfort >Assist patient in doing her activities of daily living. Helps reduce pain brought about by the exertion of force necessary to perform activities >Encourage patient to report pain as soon as it starts and allow her to verbalize pain experienced or describe the pain shes feeling. Severe pain is more difficult to control and increases the clients anxiety and fatigue.

sensitization is a type of posttraumatic stress to the spinal cord, which interprets any stimulationpainful or otherwiseas unpleasant. That is why a patient may feel pain in movement or physical touch in locations far from the surgical site)

> Administer analgesics as ordered by attending physician

Assessment Subjective: inoperahan ako sa tiyan gawa nga nang may bato sabi ng doktor, as verbalized by the patient

Diagnosis Impaired skin integrity related to laparoscopic cholecystectomy surgery secondary to calculous cholecystitis.

Planning At the end of 8 hours of nursing intervention the patient will be able to display improvement in wound healing

Nursing Interventions >monitor vital signs especially temperature every 4 hours. Early recognition of developing infection enables rapid institution of treatment and prevention of further complications.

Evaluation

Objective: >post laparoscopic cholecystectomy >disruption of the dermis, epidermis, and subcutaneous tissues. >with 0.5 to 1 cm incisions at the epigastrium, right lower rib cage and below the umbilicus ->ncisions covered with dry and intact dressing >skin slightly warm to touch. Temperature:

(Laparoscopic cholecystectomy is a less invasive way to remove the bladder. It is performed through inserting a laparoscope just below the navel. Three additional ports are inserted by making three other incisions in the epigastrium and in the right upper quadrant of the abdomen)

At the end of 2 days nursing intervention, the patient was able maintain incision site and dressing intact >Assess dressings/ wound everyday. and dry. Describe wounds and observe for changes. this Establishes comparative baseline providing opportunity for timely intervention. >Keep the incision site clean and dry, carefully dress wounds. Keeping incision site clean and dry prevents infection; it also aids in the process of wound healing. >Encourage early ambulation. Assist patient in doing active and passive range of motion exercises. Movement stimulates circulation and assists in the bodys natural process of repair. >Place in semi-Fowlers position or moderate high back rest. Proper

36.6C

positioning decreases tension in the operative site and promotes healing. >Instruct to wear clean, dry, loosefitting clothes, preferably cotton fabric. Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. Loose clothing reduces pressure on compromised tissues, which may improve circulation/healing > Emphasize importance of adequate nutrition and fluid intake. Encourage patient to eat foods rich in protein, iron and vit. C. Improved nutrition and hydration will improve skin condition. Protein and iron helps in repair of tissues. Vitamin C is important for immune system function and increases resistance to some pathogens. >Administer antibiotics as indicated. May be given prophylactically or to treat specific infection and enhance healing.

Assessment Subjective: Patulong naman akong umupo, nahihirapan akong huminga as verbalized by the patient

Diagnosis Ineffective breathing pattern related to incision as evidenced by verbalization of the patient.

Planning After one hour of nursing intervention, the patient will be able to breathe without difficulty

Nursing Interventions >monitor vital respirator rate signs

Evaluation

especially After one hour of nursing intervention, the >encourage to have deep breathing patient was able exercise with rolled towel pressure on to breathe with incision site. ease. >encourage patient to position on comfort >keep the patient dressing dry >drain foley catheter to urinary bag frequently >advise patient to avoid overeating gas-forming foods that may cause abdominal distention >give analgesic as prescribed by the physician to promote deeper respiration

Objective: >nasal flaring >use of accessory muscles to breath >RR:

Assessment S Dok, nagnanana oh!, as verbalized by the patient O -T: 38C - WBC of 14.1 _ pain on the incision sites (8/10) -(+)pus -redness on the incision site -with foley catheter

Diagnosis Risk for infection related to laparoscopic cholecystectomy surgery

Planning After 8 hours of nursing intervention, the patients risk of infection will be lessen

Nursing Interventions

Evaluation

>monitor vital signs. Any alteration in After 8 hours of temperature and blood pressure nursing intervention, the indicates infection invasion. patients risk >keep the patient dressing dry to decreased. prevent accumulation of microbes (especially when soaked in blood). >drain foley catheter to urinary bag frequently multiplication to of lessen risk of Foley

bacteria.

catheter opens the urinary system to pathogens. Teach patient and relatives of proper hand hygiene to prevent further

transfer of infection. >encourage the patient to increase fluid intake to promote hydration of client. > Use aseptic technique to lessen the risk in cleaning the wound and draining the catheter >Use hand sanitizers with alcohol based and have handwashing before having any contact to the client