Guys, hi, I'm a 3rd year nursing student, and I'm wondering if you could check out my nursing care plan, to see if it's good enough.. I've learned a lot from your conversation here and i really need your help with this one. Comments and suggestions will help.
The patient is a 31 y/o female, 2 days post-cholecystectomy.
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| Subjective: |
“Masakit ang tahi ko.” – as verbalized by the patient
Ø Reports pain to be 7 in a scale of 10
Ø Facial grimace
Ø Guarding behavior
Ø T = 37.8C
Ø post cholecystectomy (2nd day), abdominal incision on the RUQ
| Acute pain r/t surgical incision as manifested by verbalized pain of 7 in a scale of 10 and evident facial grimace |
| Break in the skin integrity prompts the body to produce chemical responses to combat such injury. A release of chemical mediators causes inflammatory process and stimulates nociceptors that produce the unpleasant sensation. || Short term goal: |
After 8 hours of nursing intervention the client will be:
1. Will verbalize a decrease in pain as evidenced by 4 in a scale of 10 in the pain scale.
Short term objectives:
Ø Will be able to state the importance of ambulation and use of coughing and deep breathing exercises.
Ø Be able to splint abdominal incision using a pillow during turning with assistance
Ø Demonstrate coughing and deep breathing exercises effectively.
Ø temperature will subside to <37C
| 1. Provide quiet and well-ventilated environment |
2. Discuss the importance of ambulation and position changes.
3. Instruct to use pillow over the incision site during turning activities.
4. Assist the patient in turning from side to side or changing of position in bed
5. Assist the patient in performing relaxation techniques such as coughing and deep breathing exercises.
6. Perform tepid sponge bath
7. Administer antipyretic and analgesics as prescribed.
8. Document client’s responses to interventions and baseline vital signs.
| 1. A quiet and well-ventilated environment promotes rest and relaxation |
2. To obtain the client’s cooperation.
3. Splinting reduces the pressure exerted by the abdominal organs through the incision site.
4. Prevents venous stasis and promotes good blood flow to dependent areas of the body
5. Full expansion of the lungs is necessary to improve gas exchange. Coughing establishes patent airway and prevents aspiration by expectorating accumulated mucus in the lungs during immobility.
6. To relieve heat from the body via conduction
7. Pharmacologic means to relieve pain and lower temperature.
8. To establish data for future comparison/evaluation.
| After 8 hours of nursing intervention, the client was able to verbalize a decrease in pain felt as evidenced by 4 in a scale of 10. |
· The patient was able to state the importance of ambulation and use of coughing and deep breathing exercises.
· The patient’s temperature subsided to 36.8C
· The patient was able to demonstrate coughing and deep breathing exercises effectively
· The patient was able to demonstrate the use of pillow as an abdominal splint during turning with assistance.
4/4 objectives – fully met
2/4 objectives – partially met
0/4 objectives – unmet
*Goal is met
*the objectives are fully met
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| Objective: |
Ø Shallow respirations
Ø RR = 12 breaths/min
Ø Prolonged expiration phases (1:3)
Ø Alterations on depth of breathing
| Ineffective breathing pattern r/t pain in the incision site as manifested by shallow respirations. || Full expansion of the lungs is required for adequate gas exchange and to prevent post-operative complications such as pneumonia and atelectasis. But due to the patient’s pain, it causes her to take shallow breaths. || Short term goal: |
After 8 hours of nursing intervention the client will be able to establish an effective respiratory pattern as evidenced by normal respiratory rate (16-22bpm) and inspiration-expiration ratio (1:2)
1. Verbalize the importance of normal breathing pattern
2. Perform relaxation and deep breathing exercises
| 1. Assess the patient’s respiratory status; Auscultate lungs sounds and record baseline vital signs. |
2. Discuss the importance of normal breathing pattern in post-operative patients.
3. Elevate the head of the bed
4. Administer analgesics as prescribed
5. Assist the patient in performing full and deep breathing exercises.
6. Encourage slower/deeper respirations, use of pursed lip technique.
7. Splint abdomen during deep breathing exercises
| 1. To establish baseline data for future comparison |
2. To obtain the patient’s cooperation.
3. To promote physiological ease of maximal inspiration
4. Pharmacologic means to provide pain relief
5. To ensure the patient’s compliance.
6. To promote effective exchange in oxygen in the lungs and to enhance carbon dioxide release.
7. Pressure from splinting provides relief during deep breathing exercises.
| After 8 hours of nursing intervention: |
· The patient was able to establish effective respiratory pattern as evidenced by RR=22, inspiratory and expiratory ratio of 1:2 and full respiratory excursion.
· The patient was able to verbalize the importance of normal breathing pattern.
· The patient was able to perform relaxation and deep breathing exercises effectively.
3/3 objectives – fully met
2/3 objectives – partially met
0/3 objectives – unmet
*the objectives are fully met
I would appreciate your help in improving my work.