Nursing Care Plan (NCP) of Acute Cholecystitis PDF

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Summary

Nursing Care Plan (NCP) of Acute Cholecycstitis with Laboratory Results and its normal findings
Prof. Dianne Mendoza as Clinical Instructor of WMSU...

Description

Western Mindanao State University College of Nursing Zamboanga City Alternative Learning System Related Learning Experience Operating Room Instructions: Answer the provided questions comprehensively following the subsequent format. A. Use the Times Roman Font Style B. Utilize at least three (3) or more references C. References should be 2015 and latest D. Output should be submitted as posted in the Google Class Assignment in PDF Format E. Use the templates in pages 5 – 8 as guides in accomplishing your output F. You will be graded according to the Rubric in pages 9-10 CASE SCENARIO: PRE-OPERATIVE PHASE ➔ A 42-year-old female patient sought consultation in the emergency department with chief complaint of severe abdominal pain in her right upper quadrant and spreads to her right shoulder and back, accompanied by nausea and vomiting. She verbalized that she has had similar pain intermittently over the past week, however, today her pain has become constant and unbearable. Upon initial assessment, vital signs showed a body temperature of 38.2 C and positive for tenderness over her abdomen upon palpation. Blood tests and abdominal ultrasound have done and revealed presence of peritonitis with diagnosis of acute calculous cholecystitis. The surgical resident ordered for a surgical procedure: Open Cholecystectomy. Patient’s symptoms of having high fever (Temp: 39C) and pain were initially managed in the Emergency Room prior to transport to the Operating Room. Antibiotic skin-testing was endorsed to the Operating Room Nurse for orders of giving IV Cefuroxime 750mg before induction of anesthesia (RA-SAB).

IMMEDIATE POST-OPERATIVE (PACU):

➔ After an hour of surgery (Cholecystectomy), the patient is transferred to the Post-Anesthesia Care Unit for immediate monitoring. Patient is arousable upon calling and an hour later the patient is fully awake, is capable of moving both upper extremities only. Patient is able to breathe spontaneously and cough two times with vital signs of BP: 120/80mmhg, RR= 20bpm, PR= 89bpm, Temp: 35.9, and 02SAT: 96% with oxygen inhalation at 2L/min via nasal cannula. Table 1.0 Laboratory Results Examinations Patient’s Result Blood Exam 1. RBC 5.0 x 1,000,000/mm3 2. Hemoglobin

14.0 g/dL

3. WBC 4. Platelets

30.2 x 1000/mm3 250 x109/L

Urinalysis 5. Appearance

Clear

6. Color

6. pH 7. Protein

8. Sp. Gravity

9. Glucose Casts WBC RBC Fecalysis

Normal Value

Indication

4.5-6.2 million/µl (microliter) Female- 12-16g/dL Male- 13-18g/dL 4.5-11 x 1billion/L 150,000-450,000 per microliter

Normal

Clear Yellow

Dark yellow

5.0 Negative

5.0-8.0 Negative 1.005-1.029

1.040

Negative None 1–2 0–1

Negative Negative 0-3 0-5

Normal Infection/Inflammation Normal

Normal Dark yellow urine is usually caused by dehydration. When a person does not receive adequate fluids, there is a higher concentration of waste products in urine. However, it may also be caused by some foods that you consume such as blackberries, coloring, vitamins & etc. Normal Normal High specific gravity in urine could indicate possible contamination, very high levels of glucose, or recently received low-molecular-weight dextran or high-density radiopaque dyes. Normal Normal Normal Normal

Color

Light Clay

Consistency Occult blood Ova & parasites

Watery Negative None seen

Bacteria

++++

Stool Analysis:

Negative

Shades of brown (sometimes yellowish) Solid and formed Negative Negative Negative Negative

Light clay stool color could indicate barium ingestion and/or bile duct obstruction. Watery stool could indicate diarrhea. Normal Normal Representation of Bacteria (normal flora) or Infection. Normal

Laboratory findings are indicated above in Table 1.0, wherein the attending physician concludes to proceed with antibiotic regimen via intravenously. Medications on Board: 1. 2. 3. 4.

Metoclopramide 10mg IV q8 prn for vomiting Paracetamol 300mg IV prn for temp >37.8 Cefuroxime 750mg IV ANST ( ) prior to induction of anesthesia Tramadol 50mg IV prn for moderate to severe pain

1. Formulate one Nursing Care Plan, NANDA approved Nursing Diagnosis. • Give at least two (2 PRIOROTIZED) o Impaired Physical Mobility o Risk for Infection • PRIORITIZE the problems and cite your reference/s

3. Nursing Care Plan ASSESSMENT Subjective cues: • Patient is capable of moving both upper extremities only. Objective cues: • Inability to move lower extremities.

NURSING DIAGNOSIS Impaired Physical Mobility related to Decrease in Muscle Mass, Control, or Strength as evidenced by Inability to Move Lower Extremities

PLANNING OBJECTIVE OF CARE At the end of 8-hour nursing intervention, the patient will be able to: • Perform physical activity independently or within limits of disease.

INTERVENTION

RATIONALE

IMPLEMENTATION

Independent •

Assist patient for muscle exercises as able or when allowed out of bed; execute abdominal-tightening exercises and knee bends; hop on foot; stand on toes.

•

Adds to gaining enhanced sense of balance and strengthens compensatory body parts.

•

Present a safe environment: bed rails up, bed in a down position, important items close by.

•

These measures promote a safe, secure environment and may reduce risk for falls.

Execute passive or active assistive ROM exercises to all extremities.

•

•

Exercise enhances increased venous return, prevents stiffness, and maintains muscle strength and stamina. It also avoids contracture deformation, which can build up quickly and could hinder prosthesis usage.

•

Turn and position the patient every 2 hours or as needed.

•

Position changes optimize circulation to all tissues and relieve pressure.

•

Let the patient accomplish tasks at his or her own pace. Do not hurry the patient. Encourage independent activity as able and safe.

•

Healthcare providers and significant others are often in a hurry and do more for patients than needed. Thereby slowing the patient’s recovery and reducing his or her confidence.

•

Assisted patient for muscle exercises as able or when allowed out of bed; execute abdominal-tightening exercises and knee bends; hop on foot; stand on toes.

•

Presented a safe environment: bed rails up, bed in a down position, important items close by.

•

Executed passive or active assistive ROM exercises to all extremities.

•

Turned and positioned the patient every 2 hours or as needed.

•

Have let the patient accomplishes tasks at his or her own pace. Did not hurry the patient. Encouraged independent activity as able and safe.

EVALUATION After 8 hours of nursing intervention, the goal was partially met. The patient has: • Performed physical activity independently or within limits of disease.

•

•

Follow prescribed pharmacological regimen.

Dependent

Demonstrate the use of adaptive devices to increase mobility

Inter/ Collab • Show the use of mobility devices, such as the following: trapeze, crutches, or walkers.

•

•

•

Administer prescribed medications, as appropriate.

Collaborate with physical medicine specialist and occupational or physical therapists in providing range-of-motion exercise, isotonic muscle contractions, assistive devices, and activities.

•

Antispasmodic medications may reduce muscle spasms or spasticity that interferes with mobility; analgesics may reduce pain that impedes movement.

•

Administered prescribed medications, as appropriate

• •

These devices can compensate for impaired function and enhance level of activity. The goals of using such aids are to promote safety, enhance mobility, avoid falls, and conserve energy.

•

Showed the use of mobility devices, such as the following: trapeze, crutches, or walkers.

•

To develop individual exercise and mobility program, to identify appropriate mobility devices, and to limit or reduce effects and complications of immobility.

•

Collaborated with physical medicine specialist and occupational or physical therapists in providing range-ofmotion exercise, isotonic muscle contractions, assistive devices, and activities.

Followed prescribed pharmacological regimen.

Demonstrated the use of adaptive devices to increase mobility

Reference/s: Doenges, M. A., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales (15th ed.). F.A. Davis Company. Wayne, G. B. (2019, March 18). Impaired Physical Mobility Nursing Care Plan. Nurseslabs. https://nurseslabs.com/impaired-physicalmobility/#:%7E:text=Impaired%20Physical%20Mobility%20is%20characterized%20by%20the%20following,3%20Limited%20ROM%204%20Reluctance%20to%20attempt%20movement...