Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Actual 1.Provide pt. with 1.Allows pt. to relax Goal met:
1.Acute Pain Throughout
Pt. states that non-pharma- and distract attention After 8
related to the the 8 hours of
the security nursing cological ways to away from pain. hours of
disease process
officers from as evidenced by intervention, reduce pain. E.g. 2.Analgesics helps nursing
pt. guarding pt. will report
Kolbe Breathing exercise, with pain intervention
upper right reduced
Foundation episodes of massage. management and , the patient
quadrant of
brought him abdomen. pain. 2.Administer provide comfort. had

to the analgesics 3.Ongoing evaluation decrease

hospital medication as per will aid pt. in episodes of

because he drug chart. receiving maximum pain and

had sharp 3. Evaluate for pain pain relief without rated his
relief and inform
pain at the interfering with pain 0 on a
doctor. So that
right upper ADL’s scale of 1-
medication regimen
quadrant of can be adjusted as 4. To reduce 10.
necessary.
the gastrointestinal
2.Altered After 8 hours
4.Encourage
abdomen. nutrition less than of nursing Complete Bed Rest.
stimulations thereby
Goal met:
body require- intervention,
He rated his decreasing GI After 8
ment related to pt. will have 1. Give medication
pain at 9/10. activity. hours of
nausea as evident decrease
Maxalon 10 mg IV nursing
by pt. stating he symptoms of 1. To reduce episodes
intervention
has frequent nausea and q8h as ordered.
of nausea and , pt.
episodes of tolerate diet 2. Encourage pt. to
vomiting. tolerated
vomiting. appropriate for
Objective: eat a high-protein, small,
his condition. 2. To help the
Pt. had no frequent
high-carbohydrate,
signs of low-fat diet in small gallbladder contract portions of
respiratory Throughout his diet.
amounts more and empty on a
distress or Potential
hospitalization
Risk for infection frequently. regular basis.
shortness of
, pt. will
breath. Skin of incision site 3. Evaluate 3. To determine pt.
warm to remain free
related to post- effectiveness of response to treatment.
touch, from infection.
afebrile. operative antiemetic drugs.
Pt. guarding cholecystectomy.
his upper Goal met:
1.To decrease the
1.Maintain strict
right Throughout
chances of
quadrant of asepsis for dressing
hospitalizati
abdomen. transmitting
changes, wound
V/S taken as on, pt.
pathogens.
care, IV and
follows: remain free
T- 97.5F catheter handling.
from
P- 75 bpm 3. To treat infection or

R- 16 bpm infection.
2.Administer to reduce growth of
B/P- 120/80
antibiotics as per bacteria.
SPO2 -99%
Glucose- drug chart.
80mg/dl
Hb- 15.4 3. to help compare
3. Monitor vital
g/dl
and indicate whether
signs and signs of
there is presence of
infection.
infection.
4. Monitor
4. To help indicate
Laboratory exam
sings of infection
especially WBC
because low or high
 WBC value indicates

infection.

Actual problems and potential problem

1. Acute Pain related to the disease process evidenced by pt. guarding upper Rt. Quadrant of

abdomen.

2. 2.Altered nutrition less than body require-ment related to nausea as evident by pt. stating
he has frequent episodes of vomiting.

Potential

1. Risk for infection of incision site related to post-operative cholecystectomy.

Nursing Care Plan

Name: A.C

Age: 28 years

Dx: Post-Operative cholecystectomy