NURSING CARE PLAN

Patient Name: Patient R. Date: August 27, 2019

Age: 33 years old Diagnosis: Cholecystolithiasis
Sex: Female
NURSING OBJECTIVE PLANNED RATIONALE/
CUES/EVIDENCES RATIONALE EVALUATION
DIAGNOSIS OF CARE INTERVENTIONS PURPOSE
The client Ineffective tissue At the end of  Observe respiratory  Shallow breathing, The patient able
verbalized that breathing disintegrity the shift, the rate and depth. splinting with to breath
Pattern patient will be effectively by
the pain elicits at ↓ respirations, and
the wound and to related to stimulates
able to breath holding breath not holding
pain effectively may result in back the
her back every bradykinin, manifested by hypoventilation breathing, full
time she histamine, and no holding inspiration and
and atelectasis.
breathes. prostaglandin back the expiration,
There are periods ↓ breathing, full  Auscultate breath  Areas of effortless, quiet,
that she holds her activation of inspiration and sounds decreased or and regular.
breathing. Her RR nociceptor expiration, absent breath
is 20cpm. (pain-sensitive) effortless, sounds suggest
Pain quiet, and atelectasis,
regular. whereas
↓ adventitious
Upon friction or sounds reflect
pressure on congestion.
the wound
cause by  Position the patient in  To facilitates
breathing left side – lying in clearance of
↓ low-Fowler’s position airway
Nociceptor
stimulates  Assist the patient in  Deep breathing
coughing, huffing, and diaphragmatic
↓ and breathing efforts breathing allow for
Pain to make these more greater lung
↓ productive. expansion and
ventilation.
Ineffective
 breathing
Pattern

NURSING OBJECTIVE PLANNED RATIONALE/

CUES/EVIDENCES RATIONALE EVALUATION
DIAGNOSIS OF CARE INTERVENTIONS PURPOSE
 Splint the abdominal  To support,
incision with the use lessen the
of binder mobility and
maximized effort
in breathing
exercise.
 Explain that coughing
and respiratory  Provides
treatments will not reassurance that
loosen or damage injury will not
grafts or reopen occur and may
abdomen incision. enhance
cooperation with
therapeutic
regimen.

 Promotes
 Encourage the
tolerance for
patient’s mobility as
activities and
tolerated
helps with lung
expansion and
ventilation.