EMILIO AGUINALDO COLLEGE

School of Nursing

NURSING CARE PLAN

NAME: OBHOO, HARLEEN DATE: OCTOBER 25 2019

STUDENT #: 18-1-01891

You have a newly admitted patient Mrs. Urs Truly 40y/room 275 from ER arrived at 6am with IVF of D5NE 1L for 8 hours. He is admitted due to RUQ pain, laboratories and diagnostic
procedures done as an outpatient revealed cholelithiasis. You were able to accomplish the patient’s admission slip. Upon admission you also asses and obtained the following: Vital Signs;
BP: 130/80; PR: 88; RR: 22; Temp; 38.5; pain scale 6/10 with facial grimace, skin warm to touch. Medications ordered: Monowel 2gm IV now then Q8. Aeknil 300mg IV for temp 38C and
above. For Cholecystectomy on Oct 6, 2019 for NPO.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute pain related to After 2 hours of nursing INDEPENDENT: After 2 Hours of Nursing
Patient Verbalized: inflammation of gall bladder interventions the patient will - Monitored and - Notes progress and Interventions:
“ Masakit ang dyan ko” secondary to cholelithiasis verbalize relief from pain recorded Vital Signs changes of conditions The patient
as evidenced by pain scale and rate it as 3/10 from verbalized a pain
of 6/10 and facial grimace. 6/10. - Assessed pain - Data can be used to scale of 3/10.
characteristics( quality, identify the extent of
severity, location, pain as well as serve
OBJECTIVE: onset, duration, as baseline information
Vital Signs: precipitating and
BP: 130/80 relieving factors)
PR: 88
RR: 22
Temp: 38.5C - Encourages patient to - Reduces abdominal
Pain Scale: 6/10 assume position of tension promotes
Facial Grimace comfort and provided sense of control and
Skin Warm to touch comfort measures. promotes relaxation.
 DEPENDENT:
- Monowel 2fm IV Q8 - Antibacterial to prevent/
given at 9:15AM treat variety of
infections.

- Aeknil 300mg IV for - Pyrexia, to lower fever

temp 38 given at or body temperature.
9:20AM
- Surgical removal of the
- Notified the OR patient Gall Bladder.
is for Cholecystectomy
on Oct 06 2019.
- Surgical removal of the
COLLABORATIVE: Gall Bladder.
- Requested Department
of Surgery patient for
cholecystectomy on
Oct 06 2019
SOURCE: NANDA,2019