NURSING CARE PLAN
Patient’s Name: ________________________________________________________ Age: __________________ Sex: _________________ Date: __________________
Diagnosis: ____________________________________________________________ Surgical Operation: ____________________________________________________
ASSESSMEN NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATIO
T DIAGNOSIS N
(CUES /
CLUES)
“Masakit po Acute Pain related _x0005_ _x0005_Assess The patient Observe and document location, Assists in differentiating cause -After 2 hours
ang balikat ko to inflammatory the patient’s vital signs and will severity (0-10 scale), and of pain, and provides of nursing
at merong process as characteristics of pain at demonstrate character of pain. information about disease interventions,
presyon sa evidenced by least 30 minutes after relief of pain as progression and resolution, the patient’s
tyan ko” as reported pain of 8 evidenced by a development of complications, pain level
administration of medication
stated on a 10-point decrease level and effectiveness of decreased
scale and of pain interventions. from 8 to 7 on
-Reported that verbalization of R: To monitor effectiveness
of medical treatment for the a pain scale of
her pain is 8 pain in her
relief of abdominal pain. 0-10
on a 10-point shoulder and
scale pressure in her The time of monitoring of
demonstrates -Disease
-BP: 130/80 abdomen. vital signs may depend on
use of process,
-RR: 25 bpm the peak time of the drug
relaxation skills Promote bed rest, allowing the patient prognosis,
-PR: 95 bpm administered. to assume a position of comfort. and
Provide therapeutic
There is usually minimal pain
associated with this operation. The information regimen
abdomen will be sore as well as the about disease understood.
small incision sites, and some process,
patients have shoulder pain for the prognosis, and
first day or two. The shoulder pain Encourage use of relaxation
is caused by gas left in your treatment
abdomen during the operation. needs. techniques, and provide diversional
activities.
Dependent:
Administer 5 mg Morphine as
prescribed
Morphine is an opioid
medication used to treat
moderate to severe pain. It is
used to alleviate the symptoms
of acute pain.
Oxygen Ineffective The patient Observe and record respiratory rate, Shallow breathing, splinting After 2 hours
saturation is Breathing Pattern will Establish depth and oxygen saturation. with respirations, of
holding nursing
noted to be related to Pain as effective breath may result interventions
in
90%, 2 hours evidenced by breathing , the patient
hypoventilation or atelectasis.
after her oxygen saturation pattern and was able to
admission of 90% Experience no maintain
-Respiratory signs of Suction secretions, as necessary. This is to clear blockage in airway
rate is 16 respiratory airway. patency and
breaths per improved
compromise/co
minute Elevate the head of the bed and breathing
mplications.
Patient’s position the patient in semi fowler’s To increase the oxygen pattern as
-Oxygen flow level by allowing optimal evidenced by
respiratory rate
is increased lung expansion oxygen
to 4 remains within saturation of
established Assist patient to turn to sides every 2
liters/minute hours
95% from
limits. Promotes ventilation of all
by nasal 90%
cannula. lung segments
-Pt oxygen saturation
will increased Encourage sustained deep breaths by:
-Oxygen These techniques promotes
delivery is deep inspiration, which
changed increases oxygenation and
Using demonstration:
again to a prevents atelectasis.
highlighting slow inhalation,
face mask at Controlled breathing methods
holding end inspiration for a
4
few seconds, and passive may also aid slow respirations
liters/minute
exhalation in patients who are tachypneic.
without
Prolonged expiration prevents
improvement
air trapping.
in the oxygen
saturation
Incentive spirometry helps open
level Encourage usage of the alveoli, the part of the lungs
incentive spirometer. where gas exchange takes
place. The more surface area of
alveoli is available for gas
exchange, the better
oxygenation and waste removal
will work.
The patient
-Patient has a The patient is at risk of acquiring remained
comorbidity of infection due to the break in the free from any
DM with FBS continuity of the first line defense signs of
150 mg/dl risk for postoperative which is the skin. The patient shall infection.
-Patient has infection related to have undergone
a drain in her comorbidity of DM cholecystectomy, thus there is an
abdomen incision and suture made in the
with a small abdomen. If there is a breakage
amount of
in the skin, the pathogens will
yellowish
easily invade the body’s system
discharge.
thus increasing risk for infection.
-with
indwelling Since patient has a Diabetes mellitus
catheter and there’s an impact on the risk for
JP drain postoperative infection after
cholecystectomy as evidenced by small
amount of yellowish discharge.
[Link]
[Link]
NAME OF THE DOSAGE, DRUG
DRUG FORM, ROUTEAND INICATIONS MECHANSISM OF CONTRAINDICATIONS SIDE EFFECTS/ NURSING
(BRAND NAME FREQUENCY OF ACTIONS ADVERSE EFFECTS RESPONSIBLITIES/
AND GENERIC ADMINISTRATION PATIENT EDUCATION
NAME)
NURSING KARDEX
DATE MEDICATION REMARKS DATE DIET / TREATMENT TIME REMARKS
GENERAL LIQUID DIET
DATE DIAGNOSTIC TESTS REMARKS DATE PARENTERAL FLUIDS TIME REMARKS
INFUSED
CBC For repeat
FBS
DATE SINGLE / STAT TIME DATE PRN TIME REMARKS
ORDERS
SUCTION PATIENT
Patient’s Name: Belinda Armado Age/Sex: 49 years old/Female Date of Birth: February 20,
1972
Diagnosis: Cholecystitis, Cholelithiasis Surgical Operation: Cholecystectomy
Name of Student: ______________________________ Group No.: _____________________
Name of Clinical Instructor: ______________________________________________________