OUR LADY OF FATIMA UNIVERSITY

120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING
CHAPTER 6
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE Deficient knowledge At the end of 8 hour shift INDEPENDENT After 8 hours of nursing
regarding condition and self- the patient will be able to 1. Established rapport among the • To gain trust and cooperation to the plan of care. intervention, the goal was met by:
“I had no idea about care needs may be related to family members and the
cholelithiasis until I was rush into lack of information or ● verbalize patient. • To have a baseline data and to monitor unwanted changes that may • the patient verbalized the
misinterpretation evidenced understanding of affect the health of patient. knowledge and insights about the
the hospital”, as stated by the 2. Monitored the vital signs
by verbalization of concerns, conditions. • To understand the state of health of the patient further and the risk condition.
patient. questions, and occurrence of 3. Encouraged the patient to factors of the problem.
condition. ● verbalize necessary verbalize any concerns • the patient verbalized the
healthy habits. regarding their health status. importance of healthy eating
OBJECTIVE • To know about the knowledge of the patient about the condition.
4. Assessed the patient’s level of habits and avoidance of unhealthy
understanding about fats in order to achieve a desirable
VITAL SIGNS health condition.
Cholelithiasis condition
● TEMP: 36 Degree Celsius ● verbalize • To understand what to expect from the disease or condition and allow
● PULSE: 93 bpm understanding of self- 5. Provided the patient the patient to have a better understanding of rationale for needed • the patient verbalized importance
● RR: 21 cpm care needs. understandable explanations therapeutic intervention.
of self-care needs to promote
and therapeutic intervention
● BP: 120/70 mmHg health, prevent disease, maintain
about Cholelithiasis condition.
health.
6. Help the patient to understand that • In order to:
● reduce anxiety and the Cholelithiasis is preventable by:
o minimizes the secretion of bile salts and subsequent gallbladder ● the patient is now free from
restlessness regarding • Teach about the prescribed
spasms. The diet advances to the patient’s tolerance, and small, restlessness and anxiety.
their health diet. frequent feedings of a low-fat diet are recommended for both the
conditions. acute and chronic conditions. This diet After cholecystectomy, a
low-fat diet is used initially, and fatty foods may be introduced
gradually to the patient’s level of tolerance.

• Explain the effect of having o help the patient have a balanced diet and reduced the risk of
healthy eating habit. developing serious disease.

7. Demonstrate care for wound ● To encourages ability in caring and minimizes the danger of
dressings, or drains before complications such as to lessen the chance of infection.
surgery.

8. Advised the patient to use • To diminish anxiety and promote healing.

nonpharmacological
techniques such as relaxation
and deep breathing.