ASSESSMENT :

NURSING DIAGNOSIS : Impaired physical mobility r/t discomfort as evidenced by slowed and painful movement

SCIENTIFIC EXPLANATION : Post-operative/ Post-surgery

PLANNING :

INTERVENTION :

SCIENTIFIC RATIONALE : -Changes in V/S may indicate problem, and to address for proper intervention to be done. -This can help to minimize the pain and to support the dressing on the affected area. -To promote non pharmacological pain management.

EVALUATION :

Subjective Cues: Nahihirapan ako gumalaw, sumasakit kasi yung sugat ko kapag gumagalaw ako as verbalized by the patient Objective Cues: -Pain scale of8/10 -Requires help from other person for assistance

Discharge outcome: - Upon discharge the patient will be able to move

Independent: -Monitor V/S and assess degree of pain and immobility of the patient -Assist or instruct

Goal Achieved

The patient was able to move freely without any discomfort.

Disruption of skin surface

freely without any discomfort

Perception of pain

Short term: After 8 hours of nursing intervention the patient

patient in or to application of binder before doing some

Compensatory Mechanism

will be able to:

-Maintain or increases Impaired Mobility strength and function of affected compensatory body part Slowed movement and difficulty when moving -Demonstrate atleast 2 techniques or behaviors that enable resumption of activities.

activities -Provide comfort measures (e.g touch, repositioning, use of heat or cold packs, nurses presence), quiet

environment, and -Participate in ADLs and desired activities. calm activities -Instruct in and encourage use of relaxation techniques such as deep breathing and encourage adequate rest periods Collaborative: -Instruct the client to strictly practice the ordered diet by the physician -Provide the medications prescribed by her physician such as Mefenamic acid 500mg PRN for pain -To reduce tension on affected part and prevent fatigue.

ASSESSMENT :

NURSING DIAGNOSIS : Impaired skin integrity r/t surgery (cholecyst ectomy) as evidenced by

SCIENTIFIC EXPLANATION : Sedentary lifestyle

PLANNING :

INTERVENTION :

SCIENTIFIC RATIONALE : -Changes in V/S may indicate problem, and for comparative baseline for wound healing.

EVALUATION :

Subjective Cues: Naoperahan kasi ako tinanggal yung bato sa apdo ko as verbalized by the patient Objective Cues: -Post surgical wound on the abdominal area

Discharge outcome: - Upon discharge the patient will

Independent: -Monitor V/S and assess the incision site.

Goal Achieved

The patient was able to display timely wound healing without complications.

Accumulation of stone in the bladder

be able to display improvement on

Malfunction of the organ

her wound/incision as evidenced by -Instruct the patient and her family to strictly practice hand washing before and Short term: After 2 hours of nursing after wound care

-This can help to minimize the spread and accumulation of microorganism on the incision site.

presence of postsurgical wound on the abdomen

Post-Surgery

intact skin

Impaired skin integrity

intervention the patient will be able to: -Encourage to have frequent change in -To promotes timely wound healing and prevent

Wound on the abdomen

-Demonstrate ways of proper wound care

dressing and to keep it clean and dry

accumulation of Collaborative: -Participate in prevention measures and treatment program. -Instruct the client to strictly practice the ordered diet by the physician -Provide the medications prescribed by her physician like antibiotic such as Cefuroxime 750mg TIV anst(-) ; Metronidazole 500mg IV q8 microorganism.