III.
Nursing Care Plan
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Acute pain related Short Term: Independent Independent: Short Term:
“Katatapos ko to surgical site as 1. Monitored 1. To detect any
lang maoperahan evidenced by pain After 30 minutes of Vital Signs abnormalities or early Goal Met
kagabi “ as scale of 6/10 nursing intervention, especially blood signs of deterioration that
verbalized by the The patient will pressure, heart may indicate After 30 minutes
patient Acute pain is a decrease pain from rate, and breath hemodynamic instability of intervention the
protective 6/10 to 2/10. per minute. or respiratory distress. patient decrease
Objective: physiological Monitoring provides pain from 6/10 to
response to baseline data and helps 2/10
-Pain scale of 6/10 physical injury, guide further
involving the interventions.
-Open activation of
cholecystectomy nociceptors— 2.Assessed Pain 2. To quantify the
on September specialized sensory Level Using severity of pain and
30,2024 neurons that detect Numeric Rating evaluate the effectiveness
noxious stimuli. Scale 10/10 pain of pain management
BP:130/80 When tissue scale 10 is the strategies. This guides
O2sat:98% damage occurs, highest. appropriate interventions
RR:24 inflammatory to alleviate pain.
PR:106 mediators such as
prostaglandins and 3. To promote
bradykinin are oxygenation, improve
released, lung expansion, and
sensitizing 3.Instructed the reduce anxiety, which can
nociceptors and patient to do deep help manage pain and
transmitting pain Breathing improve overall
signals to the brain technique. respiratory function
via the spinal cord.
This process allows 4. To maximize lung
the body to expansion, enhance
recognize and 4. Positioned the respiratory effort, and
respond to injury, patient to high improve comfort,
facilitating healing fowler position. especially for patients
by promoting experiencing dyspnea or
protective respiratory distress.
behaviors.
Basbaum, A. I., & 5. Encourage the 5. Distraction techniques,
Julius, D. (2016) use of distraction such as listening to music,
techniques such watching television, or
as listening to light conversation, are
music, watching effective non-
television, or pharmacological methods
engaging in light for reducing the
conversation. perception of pain.
6. Teach the 6. Educating the patient
patient about the on the importance of
importance of reporting pain allows for
reporting pain earlier intervention,
early for effective which can prevent the
management. pain from escalating and
becoming harder to
manage.
Dependent:
1.Administered
ketorolac 30 mg
IV q 6hrs
2.Administered
nalbuphine 10 mg
IV q 6 hrs
1. To manage moderate to
severe pain and reduce
inflammation post-
amputation, ketorolac is a
nonsteroidal anti-
inflammatory drug
(NSAID) that works by
inhibiting the enzyme
cyclooxygenase (COX),
which is involved in the
synthesis
ofprostaglandins. By
reducing prostaglandin
production, ketorolac
decreases pain and
inflammation.
(National Institutes of
Health (NIH). (n.d.).
Ketorolac
2.To provide additional
pain relief, especially if
the patient is experiencing
breakthrough pain or
requires stronger
analgesia after the
amputation. Nalbuphine
is a mixed opioid agonist-
antagonist that can
provide effective pain
management with a lower
risk of respiratory
depression compared to
pure opioids.
National Institutes of
Health (NIH). (n.d.).
Nalbuphine
Assessment Nursing Diagnosis Planning Nursing Rationale Evaluation
Interventions
Subjective: Activity Short term 1.Monitored vital 1.To detect any After 1hr of
intolerance sign physiological changes that nursing
“Kailangan ko ng related to After 1hr of may indicate early signs of intervention
assistance kapag may decreased nursing complications such as GOALMET
kailangan akong gawin energy levels intervention , infection, cardiovascular
kasi masakit parin following the patiet will instability, or respiratory the patiet was
yung inoperahan sakin” surgery ( post be able to issues. Regular monitoring able to achieved
as verbalized by the operative status) achieve an 2Assessed the ensures timely an increased
patient as evidenced by increased strength to perform intervention. conditioned
need lying on conditioned active ROM such physical state
Objective bed. physical state 2 To evaluate the patient’s such as doing
as leg extensions
such as doing muscle strength and ROM as
-Open cholecystectomy ROM as or hip abduction mobility, preventing tolerated such as
on September 30,2024 Scientific tolerated such complications like muscle flexion,
rationale as flexion, atrophy or joint stiffness, abduction and
-Need assistance such as abduction 3.Inspect for signs and to determine the adduction.
changing clothes Activity intolerance and of skins breakdown appropriate level of
related to adduction. daily such as physical activity for
-Lying on bed postoperative redness, tenderness, rehabilitation. Long term
surgical incision is or open sores, After 3days
-using catheter due to pain, Long term especially over 3 To identify early signs of of nursing
inflammation, and pressure injuries and intervention
pressure points
prevent their progression
reduced mobility at After 3days GOAL
of nursing by implementing MET
the surgical site.
appropriate interventions,
These factors impair intervention thus promoting skin
the patient’s ability the patient integrity.
the patient
to perform normal will be able 4.Reposition the
was able to
to maintain maintained
physical activities patient from 4 To improve circulation, activity
activity level
as they cause supine to sitting reduce the risk of pressure level within
within
discomfort, fatigue, capabilities ulcers, and enhance capabilities
position using
and reduced as evidence respiratory function by as
bed adjustment 2- encouraging better lung
functional capacity. by can do evidenced
3x a day. expansion and preventing by can do
activities
Potter, P. A., Perry, complications associated
without activities
A. G., Stockert, P., assistance with prolonged without
& Hall, A. (2021). immobility. assistance
such as
sitting,
5. Assess the minimal
5 To determine the walking.
patient’s baseline patient’s starting point and
level of activity guide the progression of
and tolerance to activity based on their
energy levels.
movement:
6. Provide a 6 To support energy
balanced diet production and tissue
with adequate healing, which are
protein and essential for improving
activity levels.
caloric intake:
Dependent
1.Collaborate
with therapist.
Dependent
1.
Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation
“ Naoperahan ako kanina Risk for infection Short Term: Independent: Short Term:
natatakot ako baka related to presence After 8 hours of
mainfection yung of surgical After 8 hours of 1.Assessed the 1 To monitor nursing
inoeparahn sakin” as incision. nursing surgical site and for signs of intervention
verbalized by the patient. intervention the dressing every infection (e.g., GOAL MET,
patient surgical site 2hours. redness, the patient
Objective: Scientific rationale remains clean, dry, swelling, surgical site
- Open Surgical wounds and intact, with no discharge) or remained clean,
cholecystectomy increase the risk of signs of infection complications dry, and intact,
on September infection due to skin 2.Provided education like bleeding, with no signs of
30,2024 disruption, allowing Long Term: on drain ensuring early infection
- WBC result microorganisms to The surgical wound management and detection and
12.2x 109L enter the body, will remain free wound care. timely
( increase) leading to local or from signs of intervention. Long Term:
systemic infections, infection ,redness, The surgical
and factors like swelling, foul 2 To empower wound
poor aseptic odor_and decrease the patient with remained free
techniques and wbc from 12.2 to 5- knowledge and from signs of
compromised 10x 109L skills for infection ,redne
immunity. maintaining ss, swelling,
(Dellinger, 2017). hygiene, foul odor_and
preventing decreased wbc
infection, and from 12.2 to 8.6
promoting x 109L
proper healing
at home.
3.Cleaned the wound 3 To reduce the
using saline solution risk of infection
and iodine every by keeping the
4hours. wound clean
and free of
debris, while
promoting
optimal healing
conditions.
4. Encourage proper 4 To prevent
hand hygiene for the transmission
both the patient and of
caregivers before microorganisms
touching the surgical that could infect
site the wound.
5. Minimize
handling of the 5. To reduce the
surgical site and risk of
avoid unnecessary contamination
exposure of the from external
wound: sources.
6. Ensure the patient 6. To support
maintains adequate immune
nutritional intake, function and
focusing on protein promote wound
and vitamins healing.
Dependent:
1.Administered
cefuroxime 1500mg
IV
Dependent:
1.To treat or
prevent
infections
caused by
susceptible
bacteria,
cefuroxime is a
second-
generation
cephalosporin
antibiotic that
works by
inhibiting
bacterial cell
wall synthesis,
leading to cell
lysis and death.
Cefuroxime
binds to
penicillin-
binding proteins
(PBPs) on the
bacterial cell
wall, inhibiting
peptidoglycan
synthesis and
disrupting
bacterial cell
wall integrity.
National
Institutes of
Health (NIH).
(n.d.).
Cefuroxime
Assessment Diagnosis Planning Nursing Rationale Evaluation
Intervention
“ For sure Disturbed body Long term 1. Counseling Long term
magkaka scar to image related to 1. Provide can help the
ng Malaki sa open After 3days of psychological patient process After 3days of
tiyan ko. Di cholecystectomy nursing support through feelings related nursing
namakinis tiyan as evidenced by intervention The a one-on-one to appearance intervention
ko dahil sa verbalization of patient will counseling and improve GOAL MET,
magiging scar negative understand and session within self-esteem by The patient
nito” as feelings about accept the body the next 24 providing a safe understand and
verbalized by appearance. changes that hours to address space for accepted the
the patient happened to him body image emotional body changes
Scientific such as having a concerns. expression and that happened
Objective rationale scar on related to coping to him as
open strategies evidenced by “
-Open Disturbed body cholecystectomy. Tanggapin ko
cholecystectom image following 2. Educate the 2 Providing nalang tong
y on September an open patient on the realistic scar na to dahil
30,2024 cholecystectomy healing process expectations sa scar na to
can stem from of the surgical about scar makikita ko lagi
physical changes incision and the healing can help kung gano ako
such as scars, expected scar reduce anxiety katapang” as
altered body appearance and negative verbalized by
shape, or a within the first feelings related the patient
perceived loss of 48 hours post- to body image,
normalcy due to op. making the
the surgery. The patient feel
experience of an more in control
open surgical of their
incision can lead recovery
to negative
feelings about 3 Positive
one’s 3. Encourage affirmations can
appearance, as the patient to help shift focus
individuals may practice from perceived
feel self- positive flaws to
conscious about affirmations recovery and
visible scars, and focus on healing,
reduced their recovery, enhancing self-
mobility, or with a daily esteem and
physical session for 10 encouraging
discomfort. minutes over emotional well-
Research the next week. being
indicates that
alterations in 4 empowers the
body appearance patient,
due to surgery allowing them
can significantly 4. Involve the to regain a
impact an patient in sense of control
individual's self- selecting over their
esteem and clothing or appearance and
emotional well- accessories that improve their
being, especially can conceal the comfort with
when they surgical site or visible changes
experience enhance body
feelings of image, to be
vulnerability or done within the 5 Continuous
discomfort with first 3 days monitoring
changes in their post-surgery. allows for early
physical 5. Monitor and identification of
appearance reassess the worsening body
(Cash & patient’s body image issues,
Smolak, 2011) image ensuring timely
perceptions interventions to
during follow- support the
up visits every patient
3 days for the emotionally
first 2 weeks during recovery
post-op.
