Romeo Victor M.

Valderrama
BSN- 3A
Name: J.P.R
Admission: September 22, 2014

Date of

Age: 20
Gallbladder

CC: Polyp

Room: MSW 4
Physician: Dr. Labra

Attending

General Objective: To recognize the physiological responses of the body to disease conditions- pathological, physiological, and
compensatory.

Assessment

Nursing
Diagnosi
s

Specific
Objectiv
es

Nursing
Intervention

Rationale

Evaluation

Subjective
cues: Gasakit
pa akon pilas sa
opera as
verbalized by
client

Alteration in
comfort: Pain
related to
gallbladder
removal
secondary to
Cholelithiasis

Objective cues:

Pain scale
noted ( 7
out of 10)

Facial
grimace
noted

Restlessne
ss noted

Cautious
attitude
noted

Cholecystect
omy is the
surgical
removal of the
gallbladder.
The operation
is done to
remove
gallstones or
to remove an
infected or
inflamed
gallbladder.

Gallbladder
removal will
relieve pain,
treat infection,
and in most
cases stop

Client will be
able to
verbalize
understanding
of condition
and participate
in doing
measures to
alleviate pain.

Independent:
Assess pain,
noting
location,
intensity( scal
e of 0-10),
duration

Provide
comfort
measures,
e.g., back
rub. Helping
patient
assume
position of
comfort.
Suggest use
of relaxation/
deepbreathing
exercises,
diversional
activities

Observe
respiratory
rate/depth
Assist patient
to turn,

Provides
information
that aids in
determining
choice/effectiv
eness of
interventions.

Promotes
relaxation,
refocuses
attention, and
may enhance
coping
abilities.

Shallow
breathing,
splinting with
respirations,
holding breath
may result in

After 8 hours of nursing intervention

the client should have a pain scale
pain scale of 5/10.
Client should somehow demonstrate
signs of pain relief as evidenced by
minimal facial grimace and decreased
restlessness.

gallstones
from coming
back. The risks
of not having
surgery
Possible
complications
include
bleeding, bile
duct injury,
fever, liver
injury,
infection,
numbness,
raised scars,
hernia at the
incision,
anesthesia
complications,
puncture of
the intestine,
and death.
Cholelithiasis
is the medical
name for hard
deposits
(gallstones)
that may form
in the
gallbladder.

cough, and
deep breathe
periodically.
Show patient
how to splint
incision.
Instruct in
effective
breathing
techniques.
Elevate head
of bed,
maintain lowFowlers
position.
Support
abdomen
when
coughing,
ambulating.
Collaborative:
Administer
analgesics
before
breathing
treatments/
therapeutic
activities.

hypoventilatio
n/atelectasis.
Promotes
ventilation of
all lung
segments and
mobilization
and
expectoration
of secretions.
Facilitates lung
expansion.
Splinting
provides
incisional
support/decrea
ses muscle
tension to
promote
cooperation
with
therapeutic
regimen.
Facilitates
more effective
coughing, deep
breathing, and
activity.