Cholecystectomy Nursing Care Plan #3: Impaired Physical Mobility

Assessment Nursing Diagnosis Impaired Physical mobility related to abdominal incision secondary to post cholecystectomy Scientific Explanation Presence of surgical incision procedures causes the patient to be reluctant in doing movements such as Range Of Motion, because those may result in the stimulation of the nerve endings, during movement, thus, increase pain sensation. Planning (Objective/Goal) After 2 hours of Nursing Interventions, patient will be able to identify appropriate measures in order to move safely and freely. Nursing Interventions 1. Establish rapport Rationale Evaluation

S: Hindi ako makakilos ng maayos. O: >With postsurgical incision in RUQ of the abdomen > With dry surgical dressing in RUQ of the abdomen >Guarding Behavior in RUQ of the abdomen >Reluctance in performing Range of Motion movements

1. To establish nurse-pt. relationship 2. To establish baseline data

Did the patient confide to the nurse? Were the patients Vital Signs stable? Did the patient express frustration about immobility?

2. Monitor Vital Signs every hour 3. Note emotional responses to problems of immobility

3. Feeling of frustration or powerlessnes s may impede attainment of goals. 4. To reduce risk of pressure ulcers.

4. Support body parts/joints using pillows. 5. Schedule activities with adequate rest periods during the day.

Did the patient use pillows for support?

5. To reduce fatigue

Did the patient have adequate rest??

6. Place client in a comfortable position 7. Encourage performing diversional activities such as puzzles etc. 8. Administer medications like NSAIDS such as ketorolate (Toradol) prior to activity as needed for pain relief.

6. To lessen pain and discomfort

Was the patient comfortable?

7. Enhances self-concept and sense of independence .

Did the patient perform diversional activities?

8. To permit maximal effort / involvement in activity.

Did the patient take the medications?

Cholecystectomy Nursing Care Plan #2: Post-Operative: Acute Pain

Assessment S: Masakit ang tahi ko. O: > Pain scale of 7/10 >Guarded or protective behavior in RUQ of the abdomen >Shifts from one position to another every 3 minutes >Frowning >Inability to sleep >with RR of 23 cpm BP of 130/90mmHg PR of 110 bpm Temp of 37.6 0 C Nursing Diagnosis Acute pain related to interruption in skin, tissue and muscle integrity as evidenced by guarding or distraction behaviors and changes in vital signs. Scientific Explanation In performing cholecystectomy, surgical incision is done. By which, the incision causes direct irritation to the nerve endings by chemical mediators released at the site such as bradykinin. This irritation will send signal to the cortex and thalamus of the brain thus producing pain perception. Planning (Objective/Goal) After 2 hours of nursing interventions, the patient will report relief from pain. Interventions Rationale Evaluation

1. Monitor and record vital signs every 15 minutes 2. Assess the quality, severity, frequency, and characteristic of pain

1. Changes in
Vital signs often indicate acute pain 2. Pain is a subjective data, therefore it should be reported to rule out worsening or underlying condition or development of complications

Were there changes in the patients Vital Signs? Was the pain sharp, shooting or burning? What was the pain scale? How often does it occur?

3. Provide nonpharmacolog ical intervention such as backrub and heat and cold applications.

3. Improves circulation, reduces muscle tension and anxiety related to pain

Was the patient relieved from muscle tension and anxiety by the backrub?

4. Encourage patient to do deep breathing exercises 5. Promote adequate rest periods every hour by limiting activity 6. Provide diversional activities such as reading newspapers, listening to music and watching TV

4. To Provide relaxation and comfort

Did the patient perform deep breathing exercises?

5. To lessen pain felt by aggravated movements

Did the patient have adequate rest periods?

6. To divert the pain that the patient is experiencing

Did the patient perform diversional activities?

7. Administer IV 7. Analgesics analgesics given IV such as reach the meperidine centers (Demerol) as immediately, indicated providing more effective relief with smaller doses of medication

Was the pain relieved or controlled?

Cholecystectomy Nursing Care Plan #3: Ineffective Breathing Pattern Assessment Nursing Diagnosis Scientific Explanation Respirations may be increased as a result of pain or as an initial compensatory mechanism. However, increased work of breathing may indicate increasing oxygen consumption and energy expenditures and/or reduced respiratory reserve. Planning (Objective/Goal) After 1 hour of nursing intervention the patient will establish effective breathing pattern Interventions Rationale Evaluation

S: Nurse, Ineffective nahihirapan ako breathing huminga pattern related to pain as O: evidenced by tachypnea, >With use of respiratory depth accessory changes muscles to breath >With nasal flaring >With prolonged expiratory phases >With increased anteriorposterior diameter > With RR of 23cpm PR of 75 bpm BP of 100/80 mmHg Temp of 36.5

1. Observe Respiratory Rate and depth

1. Shallow breathing, splinting with respirations and holding breaths may result in hypoventilatio n and atelectasis 2. Areas of decreased or absent breath sounds suggest atelectasis, whereas adventitious sounds reflect congestion 3. Promotes maximal ventilation and oxygenation as well as mobilization and

Were there any changes in the Respiratory Rate?

2. Auscultate breath sounds

Were the breath sounds normal?

3. Assist patient to turn from side to side, cough and deep breath periodically. Demonstrate how to splint

Did the patient perform deep breathing exercises? Did the patient splint the incision?

incision. Instruct deepbreathing exercises and pursed lip breathing as necessary 4. Elevate head of bed; maintain lowfowlers position. Support abdomen when coughing or ambulating

expectoration of secretions

4. Facilitates lung expansion. Splinting provides incisional support and decreases muscle tension to promote cooperation with therapeutic regimen 5. Maximizes expansion of lungs to prevent or resolve atelectasis

Was the head of the bed elevated? Did the patient maintain lowfowlers position? Did the patient support abdomen when coughing or ambulating

5. Assist with respiratory treatments, such as incentive spirometer

Did the patient use incentive spirometer?

6. Administer analgesics regularly or continuously by patientcontrolled analgesia (PCA), such as morphine sulfate, hydromorpho ne (Dilaudid0, and ketorolac (Tramadol)

6. Facilitates movement and effective coughing, deep breathing and activity

Did the patient use PCA?