Preoperative Problem: Acute Pain

Assessment
S: patient may
verbalize:
> unrelieved pain
O: patient may
manifest:
> (+) facial
grimaces
>appears irritable,
restlessness
>guarded or
protective
behavior
>diaphoresis
>inability to sleep
> pain on the
abdominal area

Nursing Diagnosis
Acute pain

Scientific
Explanation
The flow of bile in
the gall bladder is
obstructed due to
the presence of
stones. When the
bladder releases
bile, it contracts
and there is
spasm, thus it
cannot
adequately
release bile due
to the stone, it
stimulates the
release of
cytokines
resulting to pain.

Planning
(Objective/Goal)
Short-term:

Interventions

1. Establish
rapport
After 1-2 hours of
2. Monitor and
nursing interventions,
record vital
the patient will
signs
demonstrate behaviors 3. assess the
to relieve pain
severity,
frequency, and
characteristic
Long-term:
of pain
4. administer
After 4 hours of
medication as
nursing interventions,
ordered
the patient will report 5. provide nonpain is controlled.
pharmacologic
al intervention
such as touch
and frequent
changing of
position

Rationale
1. To gain
patients trust
and
cooperation
2. for baseline
data
3. pain is a
subjective
data,
therefore it
should be
reported and
to determine
patients level
of pain
4. to minimize/
relieve pain
5. to provide
comfort

Evaluation
Short-term:
After 1-2 hours of
nursing
interventions, the
patient shall have
demonstrated
behaviors to
relieve pain
Long-term:
After 4 hours of
nursing
interventions, the
patient shall have
reported pain is
controlled.

Activity Intolerance
Assessment

The pt.
manifested:
>difficulty
turning from one
side to another.
> generalized
weakness
>limited ROM
>needs
assistance when
moving
Pt. may
manifest:
>bed sores
>muscle
weakness

Nursing
Diagnosis

Scientific
Explanation

Activity
intolerance r/t
generalized
weakness 2
Cholecystectomy

Post-op pt.
usually is under
bed rest for few
days that may
hinder them to
their usual
activity.
Presence of
surgical incision
procedures
causes the pt.
to be reluctant
in doing
personal
activities,
because those
may result in
the stimulation
of the nerve
endings, during
movement,
thus, increase
pain sensation.

Planning
(Objective/Goal)
Short term:
the pt will
verbalize
understanding
on improvement
of activity
tolerance within
his/ her
limitation.

Interventions

>establish rapport.

Rationale

>to establish nursept. relationship.

> monitor VS.

>to establish
baseline data.

>assess pt.
Condition.

>to gather baseline

data and compare it
with normal findings.
>to gather baseline
data.

Evaluation

Short term:
Pt. shall have
verbalized
understanding
on
improvement
of activity
tolerance
within his/her
limitation

>monitor vital signs.

Long term:
the pt. will
participate in
conditioning
program to
enhance ability
to perform
activities.

>to prevent fatigue

and conserve energy.
>provide adequate rest.
>to participate in
activities.
>adjust activities to
enhance ability.
>encourage pt. to
maintain a positive
outcome
>assist pt. to lean and
demonstrate safety
measures.

>teach ways on how to

conserve energy such as
sitting when doing
activities.
>administer med prior to
activity as need.

>to enhance sense of

well being.
>to prevent injuries.

>to limit fatigue&

maximize use of
energy.

>For pain relief, to

permit maximal
effort and
involvement in
activity.

Long term:
Pt. shall have
participated in
conditioning
program to
enhance
ability to
perform
activities.

Post-Operative Acute Pain

Assessment
S: patient may
verbalize:
> unrelieved pain
O: patient may
manifest:
> (+) facial
grimaces
>appears
irritable,
restlessness
>guarded or
protective
behavior
>diaphoresis
>inability to sleep

Nursing
Diagnosis
Acute pain

Related to
In performing
cholecystectomy,
surgical incision is
done. By which,
the incision causes
direct irritation to
the nerve endings
by chemical
mediators released
at the site such as
bradykinin. This
irritation will send
signal to the cortex
and thalamus of
the brain thus
producing pain
perception.

Planning
(Objective/Goal)
Short-term:
After 2 hours of
nursing interventions,
the patient will report
relief from pain.

Long-term:
After 4 hours of
nursing interventions,
the patient report
pain is controlled.

Interventions

Rationale

1. administer
medication as
ordered

1. to minimize
the pain

2. Monitor and
record vital
signs

2. for baseline
data

3. assess the
severity,
frequency, and
characteristic of
pain

3. pain is a
subjective
data,
therefore it
should be
reported and
to determine
patients level
of pain

4. provide
divertional
activities such
as reading
newspapers
5. provide nonpharmacologial
intervention
such as touch
and frequent
changing of
position

4. to divert the
pain the
patient is
experiencing

5. to provide
comfort

Evaluation
Short-term:
After 2 hours of
nursing
interventions. the
patient shall have
reported relief
from pain.
Long-term:
After 4 hours of
nursing
interventions, the
patient shall have
reported pain is
controlled.

Fear RT Outcome of Surgery

Assessment
S: The patient
may verbalize:
> statements
about the object
of fear
> decreased self
assurance
>increased
tension;
jitteriness
O: The patient
may manifest:
>increase
alertness
>impulsive
>diaphoresis
>pallor
>muscle
tightness

Nursing
Scientific
Diagnosis
Explanation
Undergoing open
Fear r/t
cholecystectomy,
outcome
of surgery the patient may
perceive threat
like the outcome
of the surgery
that is
consciously
recognized by
the client as
danger

Planning
Interventions
(Objective/Goal)
Short-term:
1. establish rapport
After 1 hour of
nursing
interventions,
the patient will
verbalize
accurate
knowledge or
sense of safety
related to
current situation

2. monitor/ record vital

signs

Rationale
1. to gain trust of the
patient
2. for baseline data

3. assess patients condition

4. Determine clients ability

to learn

3. to note any
abnormalities within
the patient
4. to assess the capability
of the client

5. Provide information
relevant to the situation
Long-term:
After 4 hours of
nursing
intervention the
patient will
demonstrate
understanding
through use of
effective coping
behaviors and
resources

6. compare verbal and

nonverbal responses

7. note degree of
concentration or focus
8. stay with the client

Evaluation
Short-term:
After 1 hour of
nursing
interventions, the
patient shall have
verbalized
accurate
knowledge or
sense of safety
related to current
situation
Long-term:

5. to present reality to
the patient

6. to note congruencies
or misperceptions of
situation
7. identifies the starting
point of what to do

8. sense of
abandonement can
exacerbate fear

After 4 hours of
nursing
interventions, the
patient shall have
demonstrated
understanding
through use of
effective coping
behaviors and
resources

Impaired Physical Mobility

Assessment

S>
O>
The pt.
manifested:
>surgical
incision on RUQ
of the abdomen
>guarding
behavior
The pt. may
manifest:
>cold clammy
skin
>perspiration
>anxiety
>restlessness

>redness on
the incision site

Nursing
Diagnosis

Scientific
Explanation

Impaired
Physical
mobility r/t
pain 2
Cholecyste
ctomy

Presence of
surgical
incision
procedures
causes the pt.
to be reluctant
in doing
movements
such as ROM,
because those
may result in
the
stimulation of
the nerve
endings,
during
movement,
thus, increase
pain
sensation.

Planning
(Objective/Goa
l)

Interventions

Rationale

>establish rapport.

>to establish nurse-pt.

relationship.

After 1 of NI,
pt. will be able
to identify
appropriate
interventions
or measures in
order to move
safely and
freely

>monitor V/S.

>to establish baseline data.

>assess the degree of pain.

>to determine appropriate

interventions.

>note emotional responses

to problems of immobility.

>feeling of frustration or
powerlessness may impede
attainment of goals.

Long term:

>instruct SO to stay at
bedside.

>for position
changes/transfers.

>support body parts/joints

using pillows.

>to maintain position of

function and reduce risk of
pressure ulcers.

>Administer medications
prior to activity as needed
for pain relief.

>to permit maximal effort /

involvement in activity.

>Schedule activities with

adequate rest periods
during the day.

>to reduce fatigue.

Short term:

After 3 of NI,
pt. will
demonstrate
behaviors that
enable
resumption of
activities.

Evaluation

Short term:
Pt. shall have
identified
appropriate
interventions or
measures in
order to move
safely and
freely.

Long term:
Pt. shall have
demonstrated
behaviors that
enable
resumption of
activities.

Ineffective Breathing Pattern

Assessment
S:
O: The patient
may manifest:
>tachypnea
>reluctance to
cough
>holding breath
> DOB

Nursing
Diagnosis
Ineffective
breathing pattern
r/t to pain

Scientific
Explanation
Respirations may
be increased as a
result of pain or
as an initial
compensatory
mechanism.
however,
increased work of
breathing may
indicate
increasing oxygen
consumption and
energy
expenditures
and/or reduced
respiratory
reserve.

Planning
(Objective/Goal)
Short-term:
After 1 hour of nursing
interventions, the
patient will
demonstrate
improved breathing
pattern.

Long-term:
After 4 hours of
nursing intervention
the patient will
establish effective
breathing pattern

Interventions

Rationale

1. administer
supplemental
oxygen via nasal
cannula as
ordered

1. Maximizes
available
oxygen,
especially
while
ventilation is
reduced
because pain

2. administer pain
medications as
ordered

2. to treat
underlying
cause of
respiratory
problem

3. monitor vital
signs especially
respiratory rate

3. for baseline
data

4. encourage/assist 4. promotes
with deepmaximal
breathing
ventilation
exercises and
and
pursed-lip
oxygenation
breathing as
appropriate
5. check for
5. may indicate
restlessness and
hypoxia
changes in
mental status

Evaluation
Short-term:
After 1 hour of
nursing
interventions, the
patient shall have
demonstrated
improved
breathing
pattern.
Long-term:
After 4 hours of
nursing
interventions, the
patient shall have
established an
effective
breathing pattern

Risk for Infection

Assessment
S:
O: pt. may
manifest:
>inadequate
secondary
defenses
>insufficient
knowledge to
avoid exposure to
pathogen

Nursing
Diagnosis
Risk for infection
r/t impaired
primary defense.

Scientific
Explanation
The patient is at
risk of acquiring
infection due to
the break in the
continuity of the
first line defense
which is the skin.
The patient shall
have undergone
cholecystectomy,
thus there is an
incision and suture
made in the
abdomen. If there
is a breakage in the
skin, the pathogens
will easily invade
the bodys system
thus increasing risk
for infection.

Planning
(Objective/Goal)
Short-term:

Interventions

1. monitor v/s and

assess patients
After 1 hour of nursing
condition
interventions, the
2. stress proper
patient will
hand washing
demonstrate
techniques
techniques in reducing
risk of having
3. strict
infection.
compliance to
hospital control,
sterilization,
Long-term:
and aseptic
policies
After 1 day of nursing
interventions, the
4. increase oral
patient will achieve
fluid intake if
timely wound healing,
not
be free of purulent
contraindicated
drainage, be afebrile.
5. tell patient to
comply to
antibiotic
therapy as
prophylaxis
6. monitor
medication
regimen

Rationale
1. for baseline
data
2. a first line
defense
against
nosocomial
infection or
cross
contaminatio
n
3. to establish
mechanism to
prevent
occurrence of
infection
4. to hasten
wound
healing
5. to prevent
the
occurrence of
infection
6. to determine
effectiveness
of therapy

Evaluation
Short-term:
After 1 hour of
nursing
interventions, the
patient shall have
demonstrated
techniques in
reducing risk of
having infection.
Long-term:
After 1 day of
nursing
interventions, the
patient shall have
achieved timely
wound healing,
be free of
purulent
drainage, be
afebrile.