NURSING EXPECTED

ASSESSMENT PLAN OF CARE EVALUATION

DIAGNOSIS OUTCOME

Independent: Short Term: Goals met:

Objective:  Risk for
Infection  Monitor vital signs every 4 hours.  After 30  After 1 hour
 2 days post related to minutes – 1 of nursing
cholecystectomy surgical  Assess surgical site every four (4) hours or hour of nursing intervention,
incision as indicated for any signs of infection intervention, the patient’s
 Presence of (worsening pain, redness, swelling, warmth, the patients’ risk for
surgical incision loss of sensation). risk for infection was
at right upper infection will decreased..
quadrant  Observe strict hand washing while handling be decreased.
the patient.
Long Term:
 Vital signs:  Observe aseptic technique during wound s
Temp = 36° C care and dressing change.  The patient’s  The patient’s
risk for risk for
 Keep the dressing clean and dry. infection will infection was
be minimized minimized
 Encourage coughing and deep breathing until surgical until surgical
exercises to avoid pressure on the wound. incision is incision was
healed. healed.
 Position patient away from the operative site
and avoid friction over the wound.

 Instruct patient to turn every 2 hours.

 Keep the linen wrinkled-free.

 Encourage early ambulation as allowed for

faster wound healing and to improve the
circulation.

 Provide health teachings:

• About wound care and dressing change
in preparation for discharge.

Dependent:
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 Administer antibiotics as ordered by the
physician.
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