NURSING CARE PLAN ASSESSMENT S masakit ang tiyan ko O Pain scale: 8/10 - facial grimace -irritable -guarding behavior

or -PR: 90cpm -RR: 22bpm PLANNING Within 3 hours of nursing intervention the patient will be able to rate pain on a scale of 2/10 from 8/10. INTERVENTION >Perform comfort measures to promote relaxation such as massage, bathing, repositioning and relaxation techniques. >Plan activities with patient to provide distraction, such as reading, crafts, television and visits. >Manipulate the environment to promote uninterrupted rest. >Help patient to a comfortable position and use pillows to splint or support painful areas >Apply heat or cold compress. > Collaborate with RATIONALE >These measures reduce muscle tension or spasm redistribute pressure on body parts and help patient focus on non-pain related subjects. >to help patient focus on non-pain related matters. EXPECTED OUTCOME After 3 hours of nursing intervention the patients pain scale was 2/10 from 8/10.

DIAGNOSIS Acute pain related to inflammation and distortion of the gallbladder SCIENTIFIC EXPLANATION Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute pain on the right part of the abdomen

>This promotes health, well being, and increase energy level important to pain relief. >to reduce muscle tension ort spasm and redistribute pressure on body parts. >to minimize or relive pain. > Gaining patients trust

patient in administering prescribed analgesics when alternative methods of pain control are inadequate.

and involvement helps ensure compliance and may reduce medication intake.

ASSESSMENT S O surgical incision with sutures -presence of T-tube

PLANNING Within 8 hours of nursing intervention the patients surgical wound will be able to heal without complication.

INTERVENTION > Support and instruct client in incisional support when turning, coughing, deep breathing, and ambulating. > Provide routine incisional care, being careful to keep dressing dry and sterile. Assess and maintain patency of drains.

RATIONALE > Reduces possibility of dehiscence and incisional hernia.

EXPECTED OUTCOME After 8 hours of nursing intervention the patients surgical wound will be able to heal without complication.

DIAGNOSIS Impaired Skin Integrity related to surgical incision SCIENTIFIC EXPLANATION From the surgical intervention done, which involves cutting or penetration of skin surface and layers there is injury or trauma wherein tissue is inflicted.

> Promotes healing. Accumulation of serosanguineous drainage in subcutaneous layers increases tension on suture line, may delay wound healing, and serves as a medium for bacterial growth. > Reduces pressure on skin, promoting peripheral circulation and reducing risk of skin breakdown. Skin barrier reduces risk of shearing injury > Moisture or excoriation enhances growth of bacteria that can lead to

> Encourage frequent positional change, inspect pressure points, and massage gently, as indicated. Apply transparent skin barrier to elbows and heels, if indicated. > Provide meticulous skin care, pay particular attention to skin folds common in

the very obese client. > Provide foam, water, or air mattress, as indicated. >Observe incisions periodically, noting approximation of wound edges, hematoma formation and resolution, and presence of bleeding and drainage.

postoperative infection >Reduces skin pressure and enhances circulation >Verifies status of healing, provides for early detection of developing complications requiring prompt evaluation and influencing choice of interventions.