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A sample nursing care plan (ncp) from NursingCrib.com. More care plans are on our site. http://nursingcrib.com/nursing-care-plan
NURSING CARE PLAN ASSESSMENT Subjective: “Hindi ko alam ang gagawin sa sugat ko” as verbalized by the patient. Objective: • Statement of misinterpretati on. Request for information. V/S taken as follows: T: 37.3 P: 80 R: 19 BP: 120/80 DIAGNOSIS • Knowledge deficient regarding condition and self care related to information misinterpre tation. • INFERENCE Cholecystect omy is the surgical removal of the gallbladder, a small pearshaped sac that is located directly beneath the liver in the upper right side of the abdomen. The gallbladder's main function is to store bile, which is produced by the liver, and to release it as needed for digestion. The gallbladder's function is important, but it is not • PLANNING After 8 hours of nursing interventions the patient will verbalize understanding of therapeutic needs. INTERVENTION Independent: • Review disease process, surgical procedure or prognosis. • • RATIONALE Provides knowledge base on which patient can make informed choices. Promotes independence in care and reduces risk of complications. During initial 6 months after surgery, low fat diet limits need for bile and reduces discomfort associated with inadequate digestion of fats. Minimizes the risk of pancreatic involvement. Intestines require time to adjust to stimulus of continuous output of bile. Indicators of obstruction of bile flow or altered digestion, EVALUATION • After 8 hours of nursing intervention s the patient was able verbalize understandi ng of therapeutic needs. Demonstrate care of incisions or dressing or drains. Emphasize importance of maintaining low fat diet, eating small frequent meals, gradual reintroduction of foods or fluids containing fats over 4 to 6 month period. Discuss avoiding or limiting use of alcoholic beverages. Inform patient that loose stools may occur for several months. • • • • • • • • • • Identify signs and symptoms requiring notification of healthcare • an essential organ. • provider like dark urine, jaundiced color of eyes or skin, clay colored stools. Review activity limitations depending on individual situation. requiring further evaluation and intervention. • Resumption of usual activities is normally accomplished within 4-5 weeks.
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