NURSING CARE PLAN

1. Acute pain related to presence of surgical incision secondary to status post laparoscopic
cholecystectomy.
2. Impaired skin integrity related to surgical procedure: laparoscopic cholecystectomy secondary to
calculous cholecystitis
3. Risk for infection related to presence of surgical incision.


NURSING CARE PLAN
1. Acute pain related to presence of surgical incision secondary to status post laparoscopic cholecystectomy.
Assessment Nursing Diagnosis Planning Nursing Interventions Evaluation
Subjective:
Masaki tang opera
ko as verbalized by
the patient

Objective:
pain scale of 6 out of
10
facial grimaced
Guarding behavior at
the incision sites
Slow and limited
movement of the
upper extremities
0.5 mm incision on the
right lower rib cage
and the subxyphoid
Acute pain related to
presence of surgical
incision secondary to
status post laparoscopic
cholecystectomy.
( Pain is a common
aftermath for every
surgery after the
anesthesia wore down.
Pain is recognized in two
different forms:
physiologic pain and
clinical pain. Physiologic
pain comes and goes,
and is the result of
experiencing a high-
intensity sensation. It
often acts as a safety
At the end of 3
hours nursing
intervention,
the patient will
be able to
report a
decrease in
pain intensity to
a scale of 3 out
of 10.
> Monitor and assess vital signs every
2 hours because vital signs are usually
altered in acute pain
>Instruct and demonstrate to the
patient the use of deep breathing
exercise. Also instruct patient to do
splinting while doing deep breathing
exercises. Deep breathing increases
oxygen in the body and prevents
atelectasis. Deep breathing exercise
also provides comfort.Splinting while
doing deep breathing is to lessen the
pain upon respiration.
>Position the patient properly in bed.
Elevate head of bed. Maintain
anatomic alignment. Alignment helps
prevent pain from malposition and it
enhances comfort
At the end of
rendering 3
hours nursing
intervention, the
patient was
able to report
pain as relieved
and controlled.
area; 10mm incision
below the umbilicus.
Incisions are covered
with dry and intact
dressing.
Vital Signs: T- 36.6C;
BP- 130/90; RR-18;
PR- 81.
mechanism to warn
individuals of danger
(e.g., a burn, animal
scratch, or broken glass).
Clinical pain, in contrast,
is marked by
hypersensitivity to painful
stimuli around a localized
site, and also is felt in
non-injured areas nearby.
When a patient
undergoes surgery,
tissues and nerve
endings are traumatized,
resulting in incision pain.
This trauma overloads
the pain receptors that
send messages to the
spinal cord, which
becomes overstimulated.
The resultant central
sensitization is a type of
posttraumatic stress to
>Encourage diversional activities
(TV/radio, socialization with others,
mental imaging). These highten ones
concentration upon nonpainful stimuli to
decrease one's awareness and experience
of pain.
>Provide rest periods to facilitate
comfort, sleep, and relaxation. The
patient's experiences of pain may
become exaggerated as the result of
fatigue. Adequate rest helps provide
comfort
>Assist patient in doing her activities of
daily living. Helps reduce pain brought
about by the exertion of force
necessary to perform activities
>Encourage patient to report pain as
soon as it starts and allow her to
verbalize pain experienced or describe
the pain shes feeling. Severe pain is
more difficult to control and increases
the clients anxiety and fatigue.
the spinal cord, which
interprets any
stimulationpainful or
otherwiseas
unpleasant. That is why a
patient may feel pain in
movement or physical
touch in locations far from
the surgical site)
> Administer analgesics as ordered by
attending physician


Assessment Diagnosis Planning Nursing Interventions Evaluation
Subjective:
inoperahan ako sa
tiyan gawa nga nang
may bato sabi ng
doktor, as verbalized
by the patient

Objective:
>post laparoscopic
cholecystectomy
Impaired skin integrity
related to laparoscopic
cholecystectomy surgery
secondary to calculous
cholecystitis.

(Laparoscopic
cholecystectomy is a less
invasive way to remove
the bladder. It is
performed through
At the end of 8
hours of
nursing
intervention the
patient will be
able to display
improvement in
wound healing
>monitor vital signs especially
temperature every 4 hours. Early
recognition of developing infection
enables rapid institution of treatment
and prevention of further
complications.

>Assess dressings/ wound everyday.
Describe wounds and observe for
changes. this Establishes comparative
baseline providing opportunity for
timely intervention.

At the end of 2
days nursing
intervention, the
patient was able
maintain
incision site and
dressing intact
and dry.
>disruption of the
dermis, epidermis, and
subcutaneous tissues.
>with 0.5 to 1 cm
incisions at the
epigastrium, right lower
rib cage and below the
umbilicus
->ncisions covered with
dry and intact dressing
>skin slightly warm to
touch. Temperature:
36.6C

inserting a laparoscope
just below the navel.
Three additional ports are
inserted by making three
other incisions in the
epigastrium and in the
right upper quadrant of
the abdomen)
>Keep the incision site clean and dry,
carefully dress wounds. Keeping
incision site clean and dry prevents
infection; it also aids in the process of
wound healing.

>Encourage early ambulation. Assist
patient in doing active and passive
range of motion exercises. Movement
stimulates circulation and assists in the
bodys natural process of repair.

>Place in semi-Fowlers position or
moderate high back rest. Proper
positioning decreases tension in the
operative site and promotes healing.

>Instruct to wear clean, dry, loose-
fitting clothes, preferably cotton fabric.
Skin friction caused by stiff or rough
clothes leads to irritation of fragile skin
and increases risk for infection. Loose
clothing reduces pressure on
compromised tissues, which may
improve circulation/healing

> Emphasize importance of adequate
nutrition and fluid intake. Encourage
patient to eat foods rich in protein, iron
and vit. C. Improved nutrition and
hydration will improve skin condition.
Protein and iron helps in repair of
tissues. Vitamin C is important for
immune system function and increases
resistance to some pathogens.

>Administer antibiotics as indicated.
May be given prophylactically or to
treat specific infection and enhance
healing.


Assessment Diagnosis Planning Nursing Interventions Evaluation
Subjective:
Patulong naman akong
umupo, nahihirapan
akong huminga as
verbalized by the
patient

Objective:
>nasal flaring
Ineffective breathing
pattern related to incision
as evidenced by
verbalization of the
patient.

After one hour
of nursing
intervention,
the patient will
be able to
breathe without
difficulty
>monitor vital signs especially
respirator rate
>encourage to have deep breathing
exercise with rolled towel pressure on
incision site.
>encourage patient to position on
comfort
>keep the patient dressing dry
>drain foley catheter to urinary bag
After one hour
of nursing
intervention, the
patient was able
to breathe with
ease.
>use of accessory
muscles to breath
>RR:
frequently
>advise patient to avoid overeating
gas-forming foods that may cause
abdominal distention
>give analgesic as prescribed by the
physician to promote deeper
respiration



Assessment Diagnosis Planning Nursing Interventions Evaluation
Risk for infection related
to laparoscopic
cholecystectomy surgery
After 8 hours of
nursing
intervention,
the patients
risk of infection
will be lessen
>monitor vital signs. Any alteration in
temperature and blood pressure
indicates infection invasion.
>keep the patient dressing dry to
prevent accumulation of microbes
(especially when soaked in blood).
>drain foley catheter to urinary bag
frequently to lessen risk of
multiplication of bacteria. Foley
catheter opens the urinary system to
pathogens.
Teach patient and relatives of proper
hand hygiene to prevent further
After 8 hours of
nursing
intervention, the
patients risk
decreased.
transfer of infection.
>encourage the patient to increase
fluid intake to promote hydration of
client.



Assessment Diagnosis Planning Nursing Interventions Evaluation