XIII.
PROBLEM LIST
Actual Problem List
Problem Number Problem Date Identified Date Resolved
1 Pain August 22, 2010 Partially resolved
2 Fever August 22, 2010 Resolved
3 Limited ROM August 22, 2010 Partially resolved
Potential Problem List
Problem Number Problem Date Identified Date Resolved
1 Risk for Infections August 22, 2010 Unresolved
2 Risk for Imbalanced August 22, 2010 Unresolved
Nutrition, Less than
Body Requirements
1
XIV. NURSING CARE PLAN
Actual problem No.1 Pain in the incision site
ASSESSMENT NURSING EXPECTED
PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS OUTCOME
S> “ masakit Acute Pain Short-Term INDEPENDENT: The patient
yung tahi ko” related to Goal: >Establish rapport >to gain will be on
incision site as patient’s good
O> The patient manifested by After the shift, trust condition and
may manifest: Facial the patient >Assess patient >to be specific free from
grimacing, will quality onset, duration, of the kind of complications
>guarding Guarding decreased the location and intensity pain
behavior on behavior, and level of pain of pain. experienced
RUQ portion of pain scale of 7 from 7 which
the stomach which is is moderate to
> Irritability moderate 0 which is no >Monitor and record >to obtain
secondary to pain vital signs. baseline data
>facial grimace post op >Provide comfort >to promote
cholecystectom Long-Term measure such as quite rest and
>unable to y Goal: environment using enhance the
move freely relaxation techniques, effects of
After backrub, comfortable analgesics
> self focusing hospitalization, positioning given
demonstrate
>narrowed use of
focus relaxation
skills, other >Provide individuals
>sleep methods to with opportunities to >to assist
disturbance promote discuss fear andpatient and
comfort and acknowledge the
family to
to relieve difficulty of situation. respond
• V/S pain. optimally to the
taken as individual’s
follows: >Provide divertional pain experience
• T: 38 activities
>to divert focus
• P: 78
of the pt. to the
• R: 16 >Maintain adequate pain.
• BP: fluid intake.
100/80 >Dehydration
pain scale of 7 increases
which is sickling
moderate and
corresponding
2
pain.
COLLABORATIVE: >Analgesics
> Administer reduces pain
medication as and
indicated like promotes rest
analgesics and and comfort,
antibiotics. while
antibiotics
inhibits further
bacterial
infection
3
Actual Problem No.2 Fever
NURSING
ASSESSM EXPECTED
DIAGNOSI PLANNING INTERVENTIONS RATIONALE
ENT OUTCOME
S
Subjective: Hypertherm Short-Term Goal: INDEPENDENT: The patient
“may ia related to • Provide tepid • Enhances temperature
lagnat sya” the After the shift, the sponge bath. heat loss by will lower
As infectious patient temperature evaporation down to
verbalized process as will lower down to normal levels:
&
by the manifested normal levels: T: T: 38°C –
husband by 38°C – 37.5°C conduction. 37.5°C and be
• Assess fluid
temperature • Increases free from any
loss & facilitate
Objective: of Long-term Goal: metabolic complication
Skin warm 38°C oral intake.
rate &
to touch After diaphoresis.
with a hospitalization, the
temperature patient will be free • Reduces
of 38°C from any • Promote bed
rest. body heat
↑RR: complication
20cpm production.
↑HR: • Provide cool • Dissipates
70bpm circulating air heat by
Weakness using a fan. convection.
observed • Increases
• Assist patient in
Dry comfort.
mucous changing into
dry clothing.
membranes
Flushed
• Prevents
Skin • Provide oral
herpetic
hygiene.
lesions of
the mouth.
• Monitor vital • Notes
signs. progress &
changes of
DEPENDENT: condition.
• Maintain IV • Prevents
fluids as dehydration.
ordered by
physician.
4
• Administer anti- • Reduces
pyretic as fever.
ordered.
• Administer • treats
antibiotic as underlying
ordered. cause.
COLLABORATIVE:
• Monitor • Indicates
hematologic test presence of
& other infection &
pertinent lab dehydration.
records.
• Discuss • Ensures
condition of the continuous
patient with intervention.
other members
of the health
care team.
5
Actual Problem No.3 Limited Range of Motion
ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EXPECTED
DIAGNOSIS OUTCOME
> monitor Vital > to obtain
S> “kani-kanina Activity Short term: signs baseline data Short term:
lang siya intolerance r/t > assess nutritional > adequate
inoperahan” as limited range of After the shift, status proteins/ calories The patient
verbalized by the motion 2o the pt. will be are needed for shall have
husband. surgical able to wound healing maintained
procedure, maintain after functional
O> cholecystectom functional Cholecystectomy alignment of
Weak in y alignment of > assess pt’s level of > aids in all
appearance all extremities mobility defining what extremities
and avoid patient is capable and avoid
> Inability in contractures of without contractures
performing ADLs compromising
without assistance the health and
(limited ROM) Long term: wellness of the Long term:
patient after
>with clean and After the cholecystectomy The patient
dry wound hospitalization, which is shall have
dressing over the pt. will be necessary before verbalized
RUQ able to setting realistic understanding
verbalize goals on health
>Exertional understanding > refrain from > patient with teachings
Discomfort on health performing non- limited activity about risk
teachings essential procedures tolerance need to factors and
Vital signs: about risk prioritize tasks individual
T- 38 C factors and in order not to treatment
P- 78 bpm individual compromise regimen and
R- 16 cpm treatment health and to safety
BP- 100/80 regimen and prevent measures
safety complications
measures such as
evisceration
> monitor patient’s > difficulties
sleep pattern and sleeping need to
amount of sleep be addressed
achieved over past before activity
few days progression can
be achieved
> involve pt. and > setting small
health care attainable goals
professionals who can increase
handle the patient in confidence and
6
goal setting and care self-esteem of
planning the patient after
the procedure
> teach about energy > to reduce
consumption oxygen
consumption
> teach appropriate > to conserve
use of energy and
environmental aids prevent injury
from fall which
may further
aggravate the
client’s
condition
> encourage pt. to > reduce feelings
verbalize concerns of fear and
about discharge and anxiety
home environment
>acknowledge > helps to
difficulty of the minimize
situation for the frustration,
client rechannel energy
> provide referral to > to develop
other disciplines as individually
indicated appropriate
therapeutic
regimens
> review > to establish
expectations of individual goals
client for faster
recovery
> assist client to > to prevent
learn appropriate injuries and
safety measures complications
that may develop
that could
aggravate the
patient’s
condition
> give client / SO > to sustain
information that motivation
provides evidence of
daily / weekly
progress
7
Potential Problem No.1 Risk for Infection
ASSESSMENT NURSING DESIRED INTERVENTIONS RATIONAL EXPECTED
DIAGNOSIS OUTCOME E OUTCOME
INDEPENDENT:
S> Risk for Short Term: >Assess underlying >to obtain Short Term:
infection r/t condition and body comparative
O> presence of After 4 hours temperature baseline data The patient
surgical of NI, the >Observe for localized >to assess shall have
incision 2o patient will be signs of infection on causative/con verbalized
surgical able to the incision site. tributing understanding
procedure, verbalize factors of health
cholecystecto understanding >Monitor and recorded > to note for teachings
my of health vital signs progress and provided to
teachings evaluate for prevent
provided to risk of spread of
prevent infection infection and
occurrence of >Encourage increase >it supports shall have
infection. fluid intake if not circulating exhibit
contraindicated volume and decrease risk
tissue of occurrence
perfusion and of infection.
Long Term: it aids in the
elimination of
After 2 days microorganis
of NI, the pt. ms that may
will be able to contribute to
exhibit the
decrease risk occurrence of
for spread of infection
infection >Promote adequate rest >reduces
periods metabolic
demands or
oxygen
>Encourage proper >decreases
hygiene the risk for
infection.
>Perform aseptic >to prevent
technique infection
>Encourage early >to decrease
ambulation risk for
infection
since prolong
immobilizatio
n can
contribute to
8
the
accumulation
of secretions
and may lead
to infection.
COLLABORATIVE:
>Administer >Analgesics
medication as reduces pain
indicated like and
analgesics and promotes rest
antibiotics. and comfort,
while
antibiotics
inhibits
further
bacterial
infection
9
Potential problem No.2 Risk for Imbalanced Nutrition: Less than Body Requirements
CUES NURSING PLANNIN NURSING RATIONA EXPECTED
DIAGNOSIS G INTERVENTI LE OUTCOME
ONS S
S> Risk for Short term: >Instruct patient >for easy Short term:
Imbalanced After the to eat soft foods digestion After the
O> Nutrition: less shift, the pt or if solid foods, and shift, the pt
than body will should be eaten prevention will
requirements demonstrate in small of reflux. demonstrate
r/t surgery increased frequent increased
appetite. feedings. >to alter appetite,
>Provide feeling of Shall manifest
diversional nausea and relief of body
Long term: activities when prevent weakness and
After there is feeling vomiting. be able to
hospitalizati of nausea or promote
on, the pt urge to vomit >to prevent wound
will report >Restrict foods indigestion. healing and
decreased which rich in prevent risk
pain fats. >to for
sensation, >Encouraged pt. decrease imbalanced
increased to position self occurrence nutrition.
appetite and to high fowlers of pain in
be able to when eating. the site of
relieve body surgery.
weakness >to
and regain >Instruct to eat promote
strength.. foods rich in vit. timely
C. wound
healing
>to regain
>Advised to eat strength
food rich in and energy.
carbohydrates
such as soft rice
or bread. >to prevent
>Promote fatigue.
adequate bed
rest.
10
XV. Nursing Progress Notes
Problem: Pain in the incision site
Date: August 22, 2010
Day: 1
Assessment:
S/O:
On the first day of duty, she looks pale and appears weak. While
she moves, she holds her abdomen as a sign of guarding behavior. She’s
facial grimace also show that she really feels pain.
Intervention:
After I visited my patient, my plans are; to check and record her
vital signs, and report any abnormal result to my Clinical Instructor. I
planned to give her any instruction that might help her to relieve the pain
that she is experiencing.
I promote comfort measures and gave her health teaching to
promote wellness. I asked her to put pillow on the affected area, to
decrease the pressure and pain.
Evaluation:
Goal unmet. After doing my Nursing Interventions, the patient is still
present..
11
Problem: Fever
Date: August 22, 2010
Day:1
Assessment:
S/O:
Another thing that I observed in my patient when I got her vital
signs was she was febrile of 38 degree Celsius.
Intervention:
After I visited my patient, my plans are; to check and record her
vital signs, and report any unnecessary remarks to my Clinical Instructor.
Since my patient was febrile, my goal is to decrease her temperature
within normal, as a nursing intervention I did tepid sponge bath. I gave
some health teachings like maintain bed rest and drink lots of water.
Evaluation:
Goal met. After doing my Nursing Interventions, the patient was
able to comply with therapeutic regimen and gradually decrease
temperature from 38 to 37.5 degree celsius.
12
Problem: Limited ROM
Date: August 22, 2010
Day:1
Assessment:
S/O:
She showed difficulty in moving, she also appears weak.
Intervention:
After I visited my patient, my plans are; to check and record her
vital signs, and report any unnecessary remarks to my Clinical Instructor.
Since she cannot move freely, I assisted her when she needed to, and
instruct her relatives to assist her in times of need.
Evaluation:
Goal unmet. After doing my Nursing Interventions, the patient still
cannot move freely.
13
REFERENCES
Books
NANDA
Nursing Spectrum Drug Handbook
Medical Surgical Nursing by Joyce M. Black
Medical Surgical Nursing by Brunner and Suddarth
Internet
https://www.merck.com/mmpe/sec03/ch030/ch030b.html
http://emedicine.medscape.com/article/774352-overview
http://www.wrongdiagnosis.com/c/cholelithiasis/intro.htm
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