ASSESSMENT DIAGNOSIS SCIENTIFIC GOAL/OBJECTIVE NURSING RATIONALE EVALUATION

BACKGROUND INTERVENTION
Subjective data: Fluid volume The Patient is 55 Short term goal: Independent: GOAL MET:
- “Nilalagnat ako, deficit Y/0 with After 2 hours of - Assess initial v/s - Helps to After 3 hours of
tapos suka ako as evidenced by complaints of Nursing and closely determine Nursing
ng suka at ang increased vomiting Intervention, the monitor. for appropriate intervention, the
sakit ng tiyan ko” body patient will be interventions of patient’s Vital
as verbalized by temperature of She was admitted able to maintain underlying Signs are stable
the patient. 38 C° secondary with a diagnosis fluid volume at a conditions with BP of
to vomiting of cholelithiasis functional level as 120/80, afebrile
Objective data: and is subjected evidenced by vital - Note presence - Signs of with a
- Patient is for open signs within of Physical signs dehydration temperature of
conscious and cholecystectomy normal limits. like dry mucous are also detected 37.4 C°.
alert but looking as surgical membrane, poor through Color of
anxious. treatment skin turgor or Skin and its
- Increased Body delayed capillary turgor.
Temperature Diarrhea and refill.
- Decreased Vomiting is one of
Venous filling; the causes which - Discuss - For her to
Hypotension decreases importance of understand that
extracellular fluid, adequate fluid oral
V/S Recorded including intake fluid replacement
TEMP: 38. C° decreased avoids
PR: 78 bpm circulating blood dehydration
RR: 18 rpm volume. due to vomiting.
BP: 100/60 mmHg
This is an effect of - Provide present - Intravenous
loss in total body IV Fluid of PNLSS Fluids
sodium which with remaining are given to
results to level of 750 ml. replace
hypotension and water, sugar and
increased body salt
temperature. for hydration
before
Patients who the procedure
experience proper.
vomiting and
diarrhea can - This will help
easily be - Closely Monitor you
dehydrated Intake and determine if her
resulting into Output of the intake is
Fluid Volume Patient adequate or
Deficit. inadequate.

Dependent: - Metoclopramide
- Administer is
metoclopramide used to prevent
10 mg IV as nausea and
ordered by the vomiting
Physician.
ASSESSMENT DIAGNOSIS SCIENTIFIC GOAL/OBJECTIVE NURSING RATIONALE EVALUATION
BACKGROUND INTERVENTION
Subjective data: Risk for aspiration The Patient is 24 Short term goal: Independent: GOAL MET:
-Ø r/t induction of Y/0 with After 1 hour of - Assess initial v/s - Helps to After 1 hour of
general complaints of Nursing and closely determine for Nursing
Objective data: anesthesia vomiting intervention, the monitor. appropriate intervention, the
- Minimized prior to surgical and diarrhea patient will show interventions of patient’s Vital
gag reflex incision as no signs of underlying Signs are stable
- Patient evidenced by She was admitted aspiration for the conditions and shows no
exhibits depressed with a diagnosis duration of her sign of aspiration
difficulty swallowing and of cholelithiasis time in the - Clear secretions - Regurgitation is for the duration
swallowing gag reflexes. and is subjected hospital. from mouth and often of her time in
without for open throat with a silent in people hospital.
choking cholecystectomy tissue or gentle with decreased
- Depressed as surgical suction. sensorium or
cough and gag treatment depressed mental
reflexed states.
Diarrhea and
V/S Recorded Vomiting is one of - Ensure a clear - The risk for
TEMP: 37.9 C° the causes which airway aspiration
PR: 78 bpm decreases increases due to
RR: 18 rpm extracellular fluid, less supervision.
BP: 100/60 mmHg including
decreased - Determine type - Some have
circulating blood of food that is difficulty with
volume. troublesome for solids, whereas
patient others have
This is an effect of difficulty with
loss in total body liquids.
sodium which
results to - Position Client - Upright position
hypotension and properly uses the force of
increased body gravity to aid
temperature. downward
 motion
Patients who of food and
experience decreases
vomiting and risk for aspiration.
diarrhea can
easily be - This positioning
dehydrated - Position (rescue
resulting into patients with a positioning)
Fluid Volume decreased level decreases the risk
Deficit. of consciousness for aspiration by
on their side. promoting the
drainage of
secretions out of
the mouth
instead of down
the pharynx,
where they
could be
aspirated.

ASSESSMENT DIAGNOSIS SCIENTIFIC GOAL/OBJECTIVE NURSING RATIONALE EVALUATION

 BACKGROUND INTERVENTION
Subjective data: Risk for infection The Patient is 24 Short term goal: Independent: GOAL MET:
-Ø related to Y/0 with After 2 hours of - Assess initial v/s - For baseline Short term goal:
cholecystectomy complaints of Nursing q15 for 2 hours data; Helps to After 2 hours of
Objective data: secondary to vomiting Intervention the and monitor determine for Nursing
- Disruption of the impaired tissue and diarrhea patient will patient’s appropriate intervention, the
skin from invasive integrity. demonstrate condition. interventions. patient already
procedure. He was admitted techniques in demonstrates
- 4 stitches on the with a diagnosis reducing risk of - Stress proper - A first line techniques in
Post-surgical of cholelithiasis having infection. handwashing defense against reducing risk of
incision site in and is subjected techniques. nosocomial having infection.
RUQ of the for open After 1 day of infection or cross
abdomen. cholecystectomy Nursing contamination. After 1 day of
- Pain and as surgical intervention, the Nursing
redness treatment patient will - Reinforce strict - To establish Intervention, the
around the achieve timely compliance to mechanism to patient have
incision site. Diarrhea and wound healing, hospital control, prevent achieved timely
Vomiting is one of be free of sterilization, and occurrence of wound healing,
V/S Recorded the causes which purulent aseptic policies. Infection. free of purulent
TEMP: 37. 9C° decreases drainage; afebrile. drainage and
PR: 78 bpm extracellular fluid, - Change surgical - To keep the afebrile with a
RR: 18 rpm including wound dressing, post-surgical temperature of
BP: 100/60 mmHg decreased using aseptic incision site dry 36.8C°
circulating blood techniques. and to avoid
volume. infection.

This is an effect of - Assess for the - Signs of

loss in total body presence of local infection
sodium which infectious include localized
results to processes swelling, redness,
hypotension and around the pain or
increased body wound. tenderness,
temperature. palpable heat.
- Increase oral - To hasten
Patients who fluid intake, if wound
experience not healing.
vomiting and contraindicated.
diarrhea can
easily be - Tell the patient - To prevent the
dehydrated to comply to occurrence of
resulting into antibiotic Infection.
Fluid Volume therapy as
Deficit. prophylaxis.

- Monitor - To determine
medication effectiveness of
regimen and IV therapy.
Infused.