NURSING CARE PLAN / G.B.S

NURSING CARE PLAN

HEALTH HISTORY:
Admission chief complain and history of present illness:
Male patient 45 year old admitted to surgical male ward as case of gallbladder stone Before one month patient complain from sever pain in general abdomen area at 11:00 am this pain lasted fro 1 hour scale 6 \10 on pain scale the this pain was disappear and after tow hours this pain was reappear but in more severe mood concentrate in right upper guardant radiated to right shoulder not relief by change position this lead patient to go to al yarmook hospital and he take an one ampoule of vortex injection then patient come back to his home and after breakfast in morning this pain come back this lead patient to go to doctor .doctor tell patient he must remove gallbladder but patient reject in that time because he was busy in his working until 20/12/2005 pain come back in uncomfortable mood then patient go to doctor and doctor was admitted him to s.m as case of gallbladder stone
History of past illnesses:
In 1985 hernia repair , no other disease with patient or hospitalization , no HTN or DM.
PHYSICAL EXAMINATION:
General appearance:
Pulse rate: 71 B/M Temperature: 37.2 cº
B.P: 120/70 R.R :18 /M
Pallor, fatigued and extremely ill
patient oriented to time place and persons
Respiratory System:
Respiratory rate: 18 Breath per minute
Respiratory rhythm: regular
No wheezing and no crackles
patient can’t take deep breathing because he feel pain in surgical area
heart :
no murmurs , normal s1,s2 sounds

nervous system :
Patient conscious, patient oriented to time, place, and persons. No peripheral sensation loss.
Musculoskeletal system:
No involuntary movement, no activity limitations, No stiffness in neck.
abdomen :
Normal color, no cyanosis, no accumulation fluid in abdomen , no umbilicus herniation , 17 cm surgical incision. no bleeding from surgical site , no discharge from surgical incision , pain around surgical area .
gastrointestinal :
no heart burn , anorexia ,


Diagnostic test :

Nursing note Normal range Range Name
elevated
4.2-6.4 mmol/L 7.6mmol/l Glucose
high 4-11*10^3/m 11.3 WBC
Normal 4.5-6*10^6m 5.9 RBC
high 150-450*10M 499 PLT
normal 135-148meq/L 144.2 Na
low 2-2.6mmol/L 1.3 Ca
normal 3.5-5.3meq/L 3.72 K
normal 53 –115umol\L 65 creatinin
normal 11 – 16 s 10s pt
normal 21 –45 s 32s ptt
high 34-55g\l 117 albumin
normal 5.1-17.1mmol\l 6 Total billirubine
normal 0-95u\l 47 amylase
Diagnostic procedure : CBC ,U/S ,abdomen x-ray

Medication

Nurs. Cons. Side effect Dose Classification Action Name
Decrease doses in renal and liver failure. Constipation, diarrhea,
nausea,
vomiting, 50mg
I.V q8h H2 antagonist Competitively inhibits the action of histamine at the histamine2 (H2) receptors of the parietal cells of the stomach, inhibiting gastric acid secretion that is stimulated by food zantac
Monitor BP carefully during IV administration Nausea,
diarrhea 10gm
IV q8h Antiemetic
GI stimulant stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic secretions; plasil
Discontinue if hypersensitivity reaction occurs. Nausea,
vomiting, diarrhea,
anorexia 1 gm
iv q8h Antibiotic
Cephalosporin third generation inhibits synthesis of bacterial cell wall, causing cell death. Claforan




Monitor B/P after & before given pethidine.
Nausea,
vomiting,
Sweating ,
change mood ,
dry mouth,
hallucination,
Facial flushing ,
hypotension, 75mg
I'm
PRN Narcotic agonist analgesic
Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same as those mediating the effects of endogenous opioids (enkephalins, endorphins). Pethidine
meperidine hydrochloride
Nursing Assessment:
Subjective data: Patient said: he feel pain in surgical area not relief by change position increase by coughing, walking and setting (pain scale6 from 10).
Patient said: he doesn’t know about a disease that happened with him and he doesn’t know about the diet.
Patient said: he doesn’t know how to care surgical site
Patient said : he afraid from death and hospitalization
Patient said: he does not drink because he afraid from vomiting
Objective data:
Pulse rate: 71 B/M Temperature: 37.2ºc
Pallor, fatigued and extremely ill
ultra sound : multiple gallbladder stone
Respiratory rate:18 Breath per minute
Respiratory rhythm: regular breathing , conscious , Low level of knowledge about disease
Patient oriented to time, persons, and place.
Patient now restricted from food just fluids and soup. No bleeding in surgical area.
albumin ,PLT, Glucose, WBC elevated
Patient takes medication (illustrated in the table above).


Nursing Diagnoses 1:
Pain related to surgical incision as manifested by patient verbalization
Planning: Goal: Relieving Pain Postoperatively
Ex. outcome: patient well able to verbalize has less pain (decreased from six to four on pain scale) at the end of my shift.
Nursing Interventions:
Have the patient splint the incision site with hand or pillow when coughing to lessen pain and protect site from increased intraabdominal pressure. Splinting and proper positing reduce the stress on the incision area.
Provide therapeutic environment—proper temperature and humidity, ventilation, visitors to decrease the tension on patient .
Put patient in comfort position to decrease pressure on surgical incision
Explaining pain relief methods, such as Breathing exercises, heat application, and progressive relaxation because Breathing exercises and relaxation techniques decrease oxygen consumption, respiratory rate, heart rate, and muscle tension, which interrupt the cycle of pain–anxiety–muscle tension
Administer analgesics, as doctor ordered.
Evaluation: Goal met. patient verbalize has less pain (decreased from 6 to 4 on pain scale)
Nursing Diagnoses 2: Impaired Skin Integrity related to invasive procedure as manifested by surgical incision.
Planning:
Goal: improving Skin Integrity
Ex. outcome: patient will be free from impairment skin integrity
Nursing Interventions:
· Assess wound for signs of swelling, and purulent drainage, which may indicate infection
· Perform hand washing before and after contact with patient to prevent contamination.
· Inspect dressings routinely and change it if necessary
· Record amount and type of wound drainage
· Turn patient frequently or encourage position changes to prevent skin breakdown at pressure areas.
· Keep suture line clean; never vigorously rub near suture line.
Evaluation: Goal not met because wound healing needs more than one shift care to maintain skin integrity
Nursing Diagnoses 3: Knowledge deficit about disease and about wound care
Planning: Goal: Educating the Patient
Ex. outcome: patient will be having good knowledge about disease and about wound care at the end of my shift.
Nursing Interventions:
Encourage questions to answer about illness.
Describe illness and relate symptom of hernia.
Answer questions honestly and completely at appropriate level.
Teach patient how to care wound and how to promote healing.
Explain all procedure and treatment and the rational for them.
Teach patient about wound care and abut early sings of infection.
Evaluation: Goal met. Patient has good knowledge about disease and about wound care
Nursing Diagnoses 4: Anxiety related to fear of death and hospitalization as manifested by patient verbalization.
Planning: Goal: Decreasing Anxiety
Ex. outcome: patient will be free from anxiety
.Nursing Interventions:
Explain to the patient and family reasons for hospitalization, diagnostic tests, and therapies administered to decrease the fear of hospitalization.
Encourage the patient to verbalize fears and concerns regarding illness through frequent conversations—conveys to the patient a willingness to listen.
Answer the patient questions with concise explanations.
Describe illness and relate symptom of diseases to notify the patient about any complication of Cholecystectomy, .
Explain all procedure and treatment and the rational for them.
Evaluation: Goal partially met patient now have no fear about his disease
Nursing Diagnoses 4:
Risk for Fluid volume deficit related to impaired fluid intake, vomiting, as manifested by patient verbalization.
Planning:
Goal: Maintaining Electrolyte and Fluid Balance
Ex. outcome: patient will be free from signs of dehydration or electrolyte imbalance during my shift.
Nursing Interventions:
Measure and record all intake and output to maintain fluid balance
Administer IV fluids as doctor order to prevent dehydration
Monitor electrolytes, urinalysis, hemoglobin, and blood cell counts and report any abnormalities to identify any abnormalities in early stages and treat it .
Monitor vital signs; a drop in blood pressure may indicate decreased circulatory volume due to blood loss from surgical procedure.
Evaluation: Goal met. Patient now free from signs of dehydration or electrolyte imbalance.
Nursing Diagnoses 5: Risk for Infection related to surgical incision
Planning: Goal: Prevent Infection
Ex. outcome: patient will be free from sign and symptom of infection during my shift
Nursing Interventions:
Check dressing for drainage and incision for redness and swelling.
Instruct patient to avoid touching incision to minimize wound contamination and injury.
Assess and accurately document condition of incision site each shift.
Keep suture line clean (may shower unless contraindicated by health care provider; avoid tub bathing until wound heals); never vigorously rub near suture line, pat dry.
Monitor for other signs/symptoms of infection: fever, chills, malaise, and diaphoresis.
Administer antibiotics as order
Evaluation: Goal met , patient now free from sign and symptom of infection.

NURSING CARE PLAN / G.B.S

NURSING CARE PLAN
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