Joya, Andrea G.

Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation

knowledge
Subjective: Acute pain related Gallstones, stone- Short term: Independent: Independent: Short term goal
“Medyo masakit to inflammatory like objects often Observe and Assists in met:
parin sa may process made of After 8hrs of document location, differentiating
bandang baba” as cholesterol or nursing severity (0–10 cause of pain, and After 8hrs of
verbalize by the bilirubin, can intervention the scale), and provides nursing
patient develop in the patient’s pain will character of pain information about intervention the
gallbladder or bile be able to (steady, disease progression patient’s pain was
Objective: ducts. Gallstones verbalized relief of intermittent, and resolution, able to verbalized
Pain scale of 9/10 can lead to pain in pain through colicky). development of relief of pain
the upper right verbalizing complications, and through
Right upper abdomen or the decreased of pain effectiveness of verbalizing
quadrant pain center of your and with a pain interventions. decreased of pain
stomach. You may scale of less than 9 and with a pain
Facial Mask of experience out of 10 Encourage use of Promotes rest, scale of 5 out of 10
pain/ Facial gallbladder pain relaxation redirects attention,
grimace from time to time Long Term: techniques such as may enhance Long Term goal
after you eat foods deep breathing coping. met:
Tenderness on that are high in fat, After 3 days of exercises. Provide
RUQ such as fried foods, nursing diversional After 3 days of
but the pain can intervention the activities. nursing
occur at almost patient’s pain will intervention the
Vital signs: any time. be controlled and Promote bedrest, Bedrest in low- patient’s pain was
T – 36.1 degree (Cleveland clinic, be absent by allowing patient to Fowler’s position controlled and
celcius 2019) verbalizing 0 out assume position of reduces intra- absent by
PR – 80 bpm of 10 on the pain comfort abdominal verbalizing 0 out
RR – 22 breaths scale and no pressure; however, of 10 on the pain
per min. tenderness felt on patient will scale and no
BP – 150/60 the right upper naturally assume tenderness felt on
mmHg quadrant least painful the right upper
position quadrant

Dependent: Dependent:
Administer Antibiotics helps to
medication such as treat the infection
 analgesic and/or process and reduces
antibiotics inflammation.
While analgesics
helps patient to
relieve the pain felt.

Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation

knowledge
Subjective: Risk for infection A surgical site Short term: Independent: Short term:
n/a related to post- infection (SSI) is Examine skin for Disruptions of skin
operative an infection that After 8hrs of breaks or irritation, integrity at or near After 8hrs of
Objective: laparoscopic occurs after nursing signs of infection. the operative site nursing
post-operative cholecystectomy surgery in the part intervention the are sources of intervention the
laparoscopic of the body where Client will remain contamination to Client was able to
cholecystectomy the surgery took free of infection, the wound. remain free of
place. Surgical site as evidenced by infection, as
infections can normal vital signs Ensure aseptic Aseptic technique evidenced by
sometimes be and absence of technique in decreases the normal vital signs
superficial signs and assessing patient’s chances of and absence of
infections symptoms of wound transmitting or signs and
involving the skin infection. spreading symptoms of
only. Other pathogens to or infection.
surgical site Long Term: between patients.
infections are Interrupting the Long Term:
more serious and After 3 days of chain of infection
can involve tissues nursing is an effective way After 3 days of
under the skin, intervention the to prevent the nursing
organs, or nurse will be able spread of infection. intervention the
implanted to maintain a safe nurse was able to
material. and aseptic Educate clients and Knowledge of maintain a safe and
Symptoms include environment for significant other ways to reduce or aseptic
Redness and pain the patient about appropriate eliminate germs environment for
around the area cleaning, reduces the the patient
Joya, Andrea G.

where you had After 3 days of disinfecting, and likelihood of After 3 days of
surgery nursing sterilizing items. transmission. nursing
Drainage of intervention the intervention the
cloudy fluid from patient will be able Perform measures These methods patient was able
your surgical Alleviate or reduce to break the chain help break the Alleviate or reduce
wound the problems of infection and chain of infection the problems
Fever (Centers for related with the prevent infection. and prevent related with the
Disease control infection. conditions that may infection.
and prevention, be suitable for
n/d) microbial growth

Encourage This promotes lung

coughing and deep expansion and
breathing exercises prevents
complication while
patient is on
healing process

Encourage sleep Adequate sleep is

and rest. an essential
modulator of
immune responses.

Dependent: Dependent:
Administer Antibiotics helps to
medication such as treat the infection
antibiotics process and
reduces the
likelihood of
infection build-up

References:

Centers for Disease control and prevention. (n.d.) Healthcare-associated infection. Retrieved from:
https://www.cdc.gov/hai/ssi/faq_ssi.html#:~:text=A%20surgical%20site%20infection%20(SSI,infections%20involving%20the%20skin%20only.
Cleveland clinic. (2019). Gallstones. Retrieved from: https://my.clevelandclinic.org/health/diseases/7313-gallstones

Drug study

Drug/freque Classifica Mechanism of Indication Side effects/ Adverse Nursing Responsibility

ncy/ dose tion action Reaction
Omeprazole proton- inhibits Eradication of Headache, abdominal pain, Inspect the skin for lesions, rash, pruritus, and dryness
40 mg IV pump secretion of H. pylori diarrhea, nausea, vomiting, to identify possible adverse effects.
OD inhibitors gastric acid by associated with liver damage, inflammation
irreversibly peptic ulcer within the kidneys Inspect and palpate the abdomen to determine
blocking the disease, Gastric potential underlying medical conditions; assess for
enzyme system and duodenal changes in bowel elimination and GI upset to identify
of ulcers, possible adverse effects.
hydrogen/potass Gastroesophage
ium adenosine al reflux disease, Provide thorough patient teaching, including the drug
triphosphatase, NSAID- name and prescribed dosage; the importance of taking
associated the drug whole without opening, chewing, or crushing
ulceration it; signs and symptoms of possible adverse effects and
measures to minimize or prevent them.

Monitor for adverse effects (GI effects, CNS changes,

dermatological effects, respiratory effects).
Amlodipine calcium Relaxes the lowers blood Dizziness, drowsiness, Monitor BP and cardiac rhythm regularly
10 mg tab channel blood vessels pressure. Used cough (rare), blurred vision,
OD blockers through for patient with headache, diarrhea, Report irregular heartbeat, shortness of breath,
vasodilation Hypertension insomnia, arthralgia, swelling of the hands or feet, pronounced dizziness,
fatigue constipation.
NaHco3 1 Antacid Increases To treat Swelling (edema), bloating, Have the patient chew tablets thoroughly and follow
tab TID plasma heartburn, belching with water to ensure that therapeutic levels reach the
bicarbonate indigestion, and stomach to decrease acidity.
levels upset stomach
Monitor for adverse effects (GI effects, imbalances in
serum electrolytes, and acid-base status).

Inspect the abdomen; auscultate bowel sounds to

ensure GI motility.
Joya, Andrea G.

Dazomet 500 Antibiotic stops the growth Works by Dizziness, headache, Take full course of drug therapy; take the drug with
mg IV q8 of certain stopping the stomach upset, nausea, food if GI upset occurs.
bacteria and growth of vomiting, loss of appetite,
parasites bacteria diarrhea, constipation, or Report severe GI upset, dizziness, unusual fatigue or
metallic taste in your mouth weakness, fever, chills.
Caco3 Tab Antacid neutralizes the used to treat Constipation, burping, Monitor hemodynamics
BID acid in the symptoms nausea, vomiting, headache Monitor and report if patient manifest hypotension,
stomach and by caused by too bradycardia, and arrhythmias
inhibiting pepsin much stomach
acid such as
heartburn, upset
stomach, or
indigestion.
Piptaz 2.25 Penicillin kills bacteria by works by killing Diarrhea, constipation, Take full course of drug therapy
mg IV q6 antibiotics inhibiting the bacteria that nausea, vomiting, Watch for seizures; notify physician immediately if
(piperacillin synthesis of cause infection heartburn, stomach pain patient develops or increases seizure activity
tazobactam) bacterial cell
walls
Carvedilol Beta- works by used to treat Dizziness, Fatigue, Low Monitor BP and pulse frequently during dose
6.25 mg/tab adrenergi blocking the high blood blood pressure adjustment period and periodically during therapy.
BID c action of certain pressure and (hypotension), Weight gain, Assess for orthostatic hypotension when assisting
blocking natural heart failure High blood sugar patient up from supine position.
agents substances in (hyperglycemia), Diarrhea
your body, such
as epinephrine,
on the heart and
blood vessels.
This effect
lowers your
heart rate, blood
pressure, and
strain on your
heart