XVII. NURSING CARE PLAN (ACTUAL AND POTENTIAL PLANNING) ASSESSMENT S:>masakit yung sugat ko..

DIAGNOSIS INFERENCE Acute Pain Inflammation of related to the gallbladder inflammation of the gallbladder as evidenced by Activation of verbal reports of nociceptor pain Bradykinins pain > Promote bedrest, allowing patient to assume position of comfort. PLANNING After 4 hours of nursing intervention the patient will report relieve of pain. INTERVENTION >Assess for reffered pain, as appropriate. RATIONALE >to help determuine possibility of underlying condition or organ dysfunction requiring treatment. Bedrest in lowFowlers position reduces intraabdominal pressure; however, patient will naturally assume least painful position. > Promotes rest, redirects attention, may enhance coping. >to maintain acceptable EVALUATION After 4 hours of nursing intervention the patient report relieve of pain. Goal was met.

O:>(+)guarding behavior (+)facial grimace > Pain scale: P-abdominal area, incison site Q-sharp pain R-scapula or shoulder S-moderate pain (7/10) T-everytime the patient moves

>Encourage use of relaxational activities

>Administer analgesics, as

indicated, to maximum dosage, as needed

level of pain. Notify physician if regimen is inadequate to meet pain control goal

ASSESSMENT S:> Nahihirapan ako sa sugat ko

DIAGNOSIS Anxiety related to change in health status,

INFERENCE Pain felt by the patient

O:> conscious and coherent >vital signs taken and recorded BP-120/80 PR-65 RR-20 Temp-36.5

Inability to cope to the disease

PLANNING At the end of 5hrs. of nursing intervention patient will be able to reduce anxiety.

INTERVENTION RATIONALE >Assess > To establish patients level of baseline data. anxiety. > Place patient in comfortable position. > To help the patient have adequate period of rest and sleep.

EVALUATION At the end of 5Hrs. of nursing intervention patient was able to reduce feeling of anxiety.

anxiety

> Provide non> To relax & pharmacological provide comfort Therapies such to the patient. as: T.V, Radio, Books, Socialization w/ others. > Provide calm activities. > Can lessen the anxiety of the patient. > To give more information about his health status.

> Provide health teaching about hepatitis disease.

ASSESSMENT O:>conscious and coherent >vital signs taken and recorded BP-120/80 PR-65 RR-20 Temp-36.5

DIAGNOSIS INFERENCE Risk for cholecystectomy Infection related to surgical incision surgical incision secondary to post cholecystectomy tissue trauma

opening of tissue

possible site of entry of pathogens causing infection

PLANNING Within 8hours of nursing interventions, the patient will be able to identify proper actions to prevent possible occurrence of infection and verbalize understandings of individual causative or risk factors of infection.

INTERVENTION RATIONALE >monitor vital > vital signs are signs important baseline data because it proves possible infection

>observe for localized Signs of infection at insertion sites and at wound site

> to assess causative and contributing factors of infection

EVALUATION After 8hours of nursing intervention, the patient will be able to identify proper actions to prevent infection and verbalize understandings of individual causative risk factors of infection.

> assess surgical incision

> to note presence of infection and wound complications > To gain trust and cooperation.

>Establish rapport. Risk for infection

> Assist patient on comfortable position.

> for patient not to strain self.

> maintain sterile technique in changing wound dressing

> to reduce or correct existing infection risk factors. > Helps prevent infection.

>Give due antibiotics

ASSESSMENT S:> ano nga po ulit yung sakit ko.. O:>conscious and coherent >vital signs taken and recorded BP-120/80 PR-65 RR-20 Temp-36.5

DIAGNOSIS Knowledge deficit related to condition, prognosis, treatment, selfcare, and discharge needs

INFERENCE Unfamiliar information

Causes confusion to the client Deficient knowledge about the disease

PLANNING After 8 hours of nurse-patient interaction the patient will verbalize understanding of disease process, prognosis, and potential complications.

INTERVENTION >Provide explanations of/reasons for test procedures and preparation needed.

RATIONALE >Information can decrease anxiety, thereby reducing sympathetic stimulation. >Provides knowledge base from which patient can make informed choices.

>Review disease process/prognosis.

EVALUATION After 8 hours of nurse-patient interaction the patient verbalize understanding of disease process, prognosis, and potential complications

Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern. Review drug regimen, possible side effects.

Effective communication and support at this time can diminish anxiety and promote healing.

ASSESSMENT O:>conscious and coherent >vital signs taken and recorded BP-120/80 PR-65 RR-20 Temp-36.5

DIAGNOSIS Risk for activity intolerance

INFERENCE PLANNING Inflammation of After 4 hours of the gallbladder nursing intervention, the Surgical patient will procedure maintain level performed of activity capability Pain for the patient

INTERVENTION RATIONALE >Promote and >to prevent/limit implement deterioration. conditioning program. Support inclusion in exercise and activity groups. >Provide information regarding potential interfering factors with activity. >which may be amenable to medication.

EVALUATION After 4 hours of nursing intervention, the patient maintain level of activity capability

Activity intolerated

>Assess patients mobility.

>this aids in defining what patient is capable of which is necessary before setting realistic goals. >these may be temporary or permanent, physical or psychological. Assessment guides treatment.

>Determine patients perception of causes of activity intolerance

XVIII. DRUG STUDY DRUG NAME CLASSIFICATION ACTION INDICATION DOSAGE/ROUTE/ NURSING FREQUENCY Generic: Ciprofloxacin Brand Name: Cipro Fluoroquinoles (Anti-infectives) Inhibits bacterial Ciprofloxacin is DNA synthesis used to treat or prevent certain , mainly by infections caused blocking DNA by bacteria. gyrase; bactericidal CONSIDERATION EVALUATION

Adults- 500 mg P.O. Obtain specimen for The patient's or 400 mg I.V. q12 culture and was free from hours infections sensitivity tests before giving first dose. Therapy may begin pending results. Be aware of drug interactions. Some require waiting up to 6 hours after ciprofloxacin administration before giving another drug to avoid decreasing drug's effects Monitor patient's intake and output and observe for any signs of crystalluria.

DRUG NAME CLASSIFICATION

ACTION

INDICATION

DOSAGE/ROUTE/ NURSING FEQUENCY CONSIDERATION Liver function test values may become elevated during therapy. Monitor transaminase, esp. ALT levels, periodically in patients undergoing long-term therapy. Don't confuse diclofenac with diflucan or duphalac. Although food delays drug absorption, it be taken may be taken with/without meals; recommended dosing time is 2 hours after a meal.

EVALUATION

Generic: Diclofenac Brand Name: Cataflam, Voltaren

Central Nervous Produces antiSystem (nonsteroidal inflammatory, anti-inflammatory analgesic, and drugs) antipyretic effects, possibly by inhibiting prostaglandin synthesis.

Diclofenac is used 75 mg P.O. b.i.d. to treat pain or diclofenac inflammation potassium or delayed-release diclofenac sodium only.

The patient was free from pain and inflammation

DRUG NAME Generic: Pantoprazole BRAND NAME: protonix

CLASSIFICATION ACTION

INDICATION

DOSAGE/ROUTE/ NURSING FREQUENCY CONSIDERATION dont confuse protonix with prilosec, prozac, or prevacid drug can be given without regard to meals do not give pantoprazole injection through the same line with other IV solutions. Immediately stop use if precipitation or discoloration occurs.

EVALUATION

gastrointestinal tract drugs ( Antiulcer drugs )

Inhibits proton pump activity by binding to hydrogenpotassium adenosine triphosphatase, located at secretory surface of gastric parietal cells, to supress gastic acid secretion.

group of drugs called proton pump inhibitors. It decreases the amount of acid produced in the stomach.

Long term treatment of pathological hypersecretory conditions: Individualize dosage. Usual starting dose is 40 mg P.O. b.i.d. Adjust dose to a maximum of 240 mg/day. Stop treatment with I.V. pantoprazole when P.O. pantoprazole is warranted.

The patient decreases the amount of acid produced in the stomach.

DRUG NAME GENERIC: Celecoxib BRAND NAME: Celebrex

CLASSIFICATION

ACTION

INDICATION

DOSAGE/ROUTE/ NURSING FREQUENCY CONSIDERATION Patients may be allergic to drug if they are allergic to or have had anaphylactic reactions to aspirin, or other NSAIDs Watch for signs and symptoms of overt and occult bleeding

EVALUATION

Central Nervous System (nonsteroidal antiinflammatory) druags

Celecoxib is used for the relief of pain, fever, swelling, and tenderness

Celecoxib is licensed Capsules: 50, 100, 200, and 400 mg for use in osteoarthritis, rheumatoid arthritis, acute pain, painful menstruation and menstrual symptoms, ankylosing spondylitis and to reduce the number of colon and rectal polyps in patients with familial adenomatous polyposis. It was originally intended to relieve pain while minimizing the gastrointestinal adverse effects usually seen with conventional NSAIDs.

The patient was relieved from pain, swelling, tenderness.

DRUG NAME Generic: Tramadol Brand name: Ultram

CLASSIFICATION ACTION

INDICATION

DOSAGE/ROUTE/ NURSING FREQUENCY CONSIDERATION Reassess patients level of pain at least 30 minutes after administration. Monitor respiratory status. Withhold dose and notify prescriber if respirations decrease or rate is below 12 bpm For better analgesic effect, give drug before onset of intense pain

EVALUATION

Central nervous System (opiod analgesics)

A centrally acting synthetic analgesic compound not chemically related to opiates. Thought to bind to opioid receptors and inhibit reuptake of norepinephrine and serotonin.

treat moderate to 50 to 100 mg P.O. severe pain. q8 hours p.r.n. as needed for pain. Tramadol extended-release is used to treat moderate to severe chronic pain when treatment is needed a round the clock.

the patient was free from severe pain.

DRUG NAME

CLASSIFICATION ACTION

INDICATION

DOSAGE/ROUTE/ NURSING FRQUENCY CONSIDERATION

EVALUATION

Generic: Cetrizine Brand name: Zyrtec

Antihistamines

A long-acting non sedating antihistamine that selectively inhibits peripheral H1, receptors.

Cetirizine is also used to treat itching and swelling caused by hives.

5 to 10 mg P.O. once daily.

Stop drug 4 days the patient was before patient free from itching undergoes diagnostic and swelling. skin tests. Drug can prevent, reduce, or mask positive skin test response. Dont confuse zyrtec with zyprexia or zantac