NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Impaired • Cholecystect • After 3 days • Change • Keeps the skin • After 3 days
tissue of nursing dressings as around the of nursing
“Masakit ang
omy is the
integrity interventions, often as needed incision clean interventions,
opera ko” as related to surgical the patient will and use karaya and provides a the patient
verbalized by the presence removal of achieve timely powder around barrier to was able to
patient. of the wound the incision. protect skin achieve timely
secretions. gallbladder, healing from wound
Objective: without excoriation. healing
which is
complications. • Use disposable • Ostomy without
• Facial mask of located in ostomy bag over appliance may complications.
pain. the abdomen a stab wound be used to
beneath the drain. collect heavy
• Limited range right side of drainage for
of motion. the liver. accurate
measurement
Gallbladder
• Disruption of of output and
skin. problems are protection of the
usually the skin.
• V/S taken as result of • Place patient in • To facilitates
follows: gallstones. low or semi- drainage of bile.
These fowlers position.
T: 37.2 • Observe for skin, • Developing
stones may
P: 90 sclerae, urine for jaundice may
R: 19 block the change of color. indicate
BP: 110/80 flow of bile obstruction of
from your the bile flow.
gallbladder, • Note color and • Clay colored
causing the consistency of stools result
stools. when bile is not
organ to present in the
swell. Other intestine.
causes • Investigate • Signs
include reports of suggestive of
cholecystitis increased right abcess of fistula
(inflammatio upper quadrant formation,
pain, requiring
n of the development of medical
gallbladder)
and fever, intervention.
cholangitis tachycardia.
(inflammatio Collaborative:
n of the bile • Administer anti- • Necessary for
duct). biotics as treatment of
prescribed. abscess or
infection.
• Monitor • Leukocytosis
laboratory studies reflects
like white blood inflammatory
cells. process.
.