Nursing Care Plan

Preoperative NCP

1.Acute Pain

Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanations Interventions
S Acute pain Due to the After 4 hours 1.Observe and - Assists in differentiating cause of Is there a change on
 related to presence of of nursing document pain, and providesinformation about the patients;a.Pain
O inflammation stones in intervention location, severity disease scaleb.RRc.BPd.Reports
-pain scale and the the patient (0–10 scale),and progression/resolution,development of paine.Facial
of 7/10 distortion of gallbladder will report character of pain of complications, and effectiveness expressions.
-difficulty the it causes relieve of (e.g., steady, ofinterventions.
in moving gallbladder some pain. intermittent,
as as evidenced obstruction colicky). - Bedrest in low-Fowler’s position
manifeste by verbal in the cystic reduces intra-abdominalpressure;
d by facial reports of duct which 2. Promote however, patient will naturally
grimaces pain. in turn bedrest, allowing assume leastpainful position.
-(+) pallor causes a patient to assume
-(+) muscle sharp acute position - Cool surroundings aid in
guarding pain on the ofcomfort. minimizing dermal discomfort.
-RR right part of
- 30 the 3. Control - Promotes rest, redirects attention,
-BP abdomen. environmental may enhance coping.
- 140/90 temperature.
- Helpful in alleviating anxiety and
4. Encourage use refocusing attention,which can
of relaxation relieve pain.
techniques, e.g.,
guidedimagery, - Relief of pain facilitates
visualization, cooperation with othertherapeutic
deep-breathing interventions,
exercises.
Providediversiona
 l activities.

5. Make time to
listen to and
maintain frequent
contact
withpatient.6.
Administer
analgesics as
indicated

2. Fluid Volume deficient

Cues Nursing Scientific Objectives Nursing Interventions Rationale Evaluation

Diagnosis Explanations
S Fluid Volume Because of After series of 1. Maintain accurate record - Provides information Is there still
 Deficient vomiting NI the pt. will of I&O, noting output less about fluid the presence
O related to excessive losses maintain thanIntake, increased urine status/circulatingvolume of;
-(+) pallor vomiting through normal adequate fluid specific gravity. and replacement needs.
-(+) body routes occur volume as Assessskin/mucous a.vomiting
weakness thus causes evidenced by membranes, peripheral - Decreases dryness of
-(+) vomiting Fluid Volume moist mucous pulses, and capillaryrefill. oral mucous b.dry skin
-with poor Deficient membranes membranes; reducesrisk
skin turgor and good skin 2. Perform frequent oral of oral bleeding. c.dry mouth
-(+) dry skin turgor hygiene
-(+) dry mouth - Skin and mucous d.poor skin
3. Provide skin and mouth membranes are dry, turgor
care with decreasedelasticity,
because of e.body
4. Increase fluid intake vasoconstriction and weakness
reducedintracellular
5. Ascertain patient’s water.
beverage preferences, and
set up a 24-hr schedule for - promotes hydration.-
fluid intake. Encourage foods Relieves thirst and
with highfluid content. discomfort of dry
mucous membranesand
6. Administer antiemetics, augments parenteral
e.g., replacement.
prochlorperazine(Compazine
) as ordered by the physician. - Reduces nausea and
prevents vomiting.
Post-operative NCP

3. Knowledge Deficit

Cues Nursing Diagnosis Scientific Objectives Nursing Rationale Evaluation

Explanations Interventions
S “pwede Deficient There is this After an hour of 1. Provide - Information can decrease -Does the
bang maulit knowledge related presence of nurse-patient explanations anxiety, thereby patient
ang sakit ko” to knowledge interaction the of/reasons for test reducingsympathetic understands
as verbalized condition,prognosis, deficit due to patient will procedures stimulation. and could
by the treatment, self- some Verbalize andpreparation recall all the
patient care, and discharge unfamiliar understanding needed. - Provides knowledge base teachings
needs information of disease from which patient can given?
O that causes process, 2. Review disease makeinformed choices.
-Frequently some prognosis, and process/prognosis. Effective communication and -Is there a
asking confusion to potential Discuss supportat this time can significant
question the client that complications. hospitalizationand diminish anxiety and changes that
about his needs to be prospective promote healing. occur on the
condition, discussed. treatment as patients
treatment indicated. - Gallstones often recur, knowledge
and diet Encouragequestions, necessitating long-term regarding;
expression of therapy.
-With concern. a.disease
worried gaze - Prevents/limits recurrence condition
3. Review drug of gallbladder attacks.
regimen, possible b.diet
side effects. - Promotes gas formation,
which can increase c.treatment
4. Instruct patient to gastricdistension/discomfort
avoid food/fluids . d.medication
high in fats
(e.g.,whole milk, ice e.self-care
cream, butter, fried needs
foods, nuts,
 gravies,pork), gas
producers (e.g.,
cabbage, beans,
onions,carbonated
beverages), or
gastric irritants (e.g.,
spicyfoods, caffeine,
citrus).

5. Suggest patient
limit gum chewing,
sucking on
straw/hardcandy, or
smoking.

b.Drug Study

Name of Drug Date Ordered Route/ Dosage Action Indication Adverse Reaction Nursing
and Frequency Consideration
GN: H2Bloc PO20 mg tab at - Anti-ulcer- -for short term - headache, 1. Check for
(Pepcidine)BN: bedtime competitively treatment of dizziness, malaise, doctor’s order2.
Famotidine inhibits action of duodenal ulcer dry mouth not to be given in
histamine on the patients
H2 at receptor hypersensitive to
sites of parietal drugs3. Inform
cells, decreasing the patient about
gastric acid the possible side
secretion effect of the
drug4. Instruct
patient to take
drug with food5.
Advised patient to
take drug once
 daily usually at
bed time6. Advise
patient to report
abdominal pain or
blood in stools or
is vomiting
GN: IV750 mg every 8 - anti-infective- a - perioperative - Nausea and 1. Check for
CefuroximeBN: o 2 prophylaxis Vomiting doctor’s order2.
Zinacef prior to OR (30 to nd Perform ANST
60 minutes generation prior to
before) cephalosporin admission3.
that inhibits cell Should not be
given if positive
-wall synthesis, skin test4. Slow IV
promoting push5. Inform the
osmotic instability patient about the
possible side
effect of the
drug6. Advise
patient to report
any discomfort on
the IV insertion
site
GN: Clomipramine PO10 mg tab, at 6 - Anti-depressants - for depression - headache, 1. Check for
HClBN: Placil am and chronic pain dizziness, malaise, doctor’s order2.
dry mouth not to be given in
patients
hypersensitive to
drugs3. Inform
the patient about
the possible side
effect of the drug
GN: Gentamicin IV80 mg amp, - Anti-infective- - endocarditis - Nausea and 1. Check for
DulfateBN: every 8 inhibits protein prophylaxis for GI Vomiting, doctor’s order
Genticin synthesis or GU procedure headache, 2. Perform ANST
or surgery dizziness prior to admission
3. Should not be
given if positive
skin test
4. Slow IV push
5. Inform the
patient about the
possible side
effect of the drug
6. Advise patient
to report any
discomfort on the
IV insertion site
7. Monitor urine
output, specific
gravity, U/A, BUN
and creatinine
levels
GN: AmpicillinBN: IV1 g amp, every 8 - Anti-infective- - endocarditis - Nausea and 1. Check for
Omnipen 0 inhibits protein prophylaxis for GI Vomiting, doctor’s order2.
synthesis or GU procedure headache, Perform ANST
or surgery dizziness prior to
admission3.
Should not be
given if positive
skin test4. Slow IV
push5. Inform the
patient about the
possible side
effect of the
drug6. Advise
patient to report
any discomfort on
 the IV insertion
site
GN: MgSO4 IV0.03% 7ml every -anti-convulsant - magnesium - drowsiness, 1. Use parenteral
12 -replaces supplementation hypotension magnesium with
magnesium and extreme caution
maintains in patients with
magnesium level impaired renal
function2. Test
knee jerk and
patellar reflexes
before each
additional dose3.
check magnesium
level after
repeated doses4.
Monitor fluid
intake and
output5. Monitor
renal function
GN: Ketorolac IV30 mg amp, - Anti- - short term - dizziness, 1. Check for
TromethamineBN: every 6 inflammatory - management of sedation, doctor’s order
Toradol inhibits moderately headache, 2. Perform ANST
prostaglandin severe, acute pain flatulence, nausea prior to admission
synthesis and vomiting 3. Should not be
given if positive
skin test
4. Slow IV push
5. Inform the
patient about the
possible side
effect of the drug
6. Advise patient
to report any
discomfort on the
 IV insertion
siteAnesthetic
drug

Anesthetic drug

Action Adverse Reaction Nursing

Consideration
GN: Lidocaine HCl IV Anesthetic drugs -lethargy, 1. Monitor BP,
hypotension PR, and RR before
and after giving
the medication2.
Monitor patient
for toxicity