NURSING DIAGNOSIS
&
CUES/EVIDENCES
OBJECTIVES
At the end of our care, the patient will be able
to:
1. Report pain is relieved/ controlled.
2. Follow the prescribed pharmacologic
SUBJECTIVE:
regimen.
“Makabatyag ko nga sakit kayo ang
3. Demonstrate use of relaxation skills
katong gi operahan”,
and diversional activities that provide
“Mu ngutngut ang tinahian
pain relief.
usahay,”
“Limitado akong paglihok kay sakit
kaayo.”
Acute Pain r/t surgical incision
secondary to Cholecystectomy
with Cholangiogram
OBJECTIVE:
- T= 37 C, P= 90 bpm, R= 18
cpm, BP= 120/80 mmHg
- Presence of surgical
incision site from
Cholecystectomy with
Cholangiogram
- Rates pain as 8 from a scale
of 0-10, with 0 as no pain
and 10 as severe pain
- Facial grimacing noted
when changing positions
INTERVENTIONS
INDEPENDENT:
1. Evaluate pain perception regularly
every 2 hours, noting
characteristics, location, and
intensity.
2. Reposition as indicated: semiFowler’s or lateral Sims’.
3. Provide comfort measures such as
back rub or cold application to
painful site.
4. Health teaching about splinting
when coughing or doing deep
breathing exercises.
5. Encourage deep-breathing
exercises.
6. Perform incentive spirometry.
7. Provide oral care, occasional ice
chips or sips of fluids as tolerated.
DEPENDENT:
1. Administer Ketorolac 30 mg q 8hrs
IVTT as prescribed by the
physician.
EVALUATION
Goals partially met. At the end of our care, the
patient:
1. Still reported pain and rated it as 7 on a
scale of 0-10, with 0 as no pain and 10
as severe pain.
2. Followed the prescribed
pharmacologic regimen.
3. Demonstrated use of relaxation skills
such as deep-breathing exercises,
incentive spirometry and splinting
when coughing or doing deepbreathing.
Impaired tissue integrity r/t
mechanical trauma to tissues
secondary to Cholecystectomy
with Cholangiogram
SUBJECTIVE:
“Mu ngutngut ang tinahian
usahay,”
“Makabatyag ko nga sakit kayo ang
katong gi operahan”
OBJECTIVE:
- T= 37 C, P= 90 bpm, R= 18
cpm, BP= 120/80 mmHg,
SaO2= 98%
- Presence of surgical
incision site from
Cholecystectomy with
Cholangiogram
- Wound dressing dry,
without presence of
bleeding
- Surgical incision site 10 cm
in length.
At the end of our care, the patient will be able
to:
1. Describe measures to protect and heal
the tissue, including wound care.
2. Demonstrates understanding of plan to
heal tissue and prevent injury.
3. Display timely healing of surgical site
without complication.
INDEPENDENT:
1. Monitor site of impaired tissue
integrity at least once daily for
color changes, redness, swelling,
warmth.
2. Provide wound care and keep a
sterile dressing technique when
doing it.
3. Health teaching on not rubbing and
scratching the wound site.
4. Health teaching on frequent
handwashing and avoiding
touching the surgical site.
5. Do not position the patient on the
incision site. If ordered, turn and
position patient at least every 2
hours, and carefully transfer
patient.
6. Maintain the head of the bed at the
lowest degree of elevation possible.
7. Encourage the use of pillows when
splinting upon deep-breathing
exercises and coughing.
DEPENDENT:
1. Administer Cefuroxime 750 mg q 8
hours IVTT ANST as prescribed.
Goals met. At the end of our care, the patient:
1. Describe measures such as frequent
handwashing, not rubbing and
scratching the wound site to protect
and heal the tissue, including wound
care.
2. Demonstrate understanding of plan to
heal tissue and prevent injury as
evidenced by cooperation and active
listening during health teachings and
verbalized, “Sige ako ning sundon para
dali ra ko ma ayo.”
3. Display timely healing of surgical site
as evidenced by surgical site dry, free
from bleeding without odor and
without any complication.
Risk for infection r/t presence of
surgical site secondary to
Cholecystectomy with
Cholangiogram
SUBJECTIVE:
““Mu ngutngut ang tinahian
usahay,”
OBJECTIVE:
- T= 37 C, P= 90 bpm, R= 18
cpm, BP= 120/80 mmHg,
SaO2= 98%
- Presence of surgical
incision site from
Cholecystectomy with
Cholangiogram
- Wound dressing dry,
without presence of
bleeding
- Surgical incision site 10 cm
in length.
At the end of our care, the patient will be able
to:
1. Be free from signs of infection.
2. Demonstrates understanding of plan to
heal tissue and prevent injury.
3. Know and understand the signs of
infection for prompt treatment.
4. Display timely healing of surgical site
without complication
INDEPENDENT:
1. Health teaching about frequent
hand washing.
2. Teach patient how to do wound
care.
3. Provide health teaching about the
signs of infection and reporting
these if it occurs to the patient.
4. Perform deep-breathing techniques
and incentive spirometry.
5. Encourage increase in fluid intake
if not contraindicated.
6. Turn and position the patient every
2 hours.
7. Encourage splinting of wound
during coughing and deep
breathing exercises.
DEPENDENT:
1. Administer Cefuroxime 750 mg q 8
hours IVTT ANST as prescribed.
POSTOPERATIVE NURSING CARE PLAN
COLLEGE OF NURSING
SILLIMAN UNIVERSITY
DUMAGUETE CITY
NURSING CARE PLAN
Goals partially met. At the end of our care, the
patient:
1. Was free from signs of infection as
evidenced by normal vital signs and
incision site kept dry, free from
bleeding and no foul odor.
2. Demonstrate understanding of plan to
heal tissue and prevent injury as
evidenced by cooperation and active
listening during health teachings and
verbalized, “Sige ako ning sundon para
dali ra ko ma ayo.”
3. Needed more explanation to
understand the signs of infection for
prompt treatment.
4. Display timely healing of surgical site
as evidenced by surgical site dry, free
from bleeding without odor and
without any complication