CARE PLAN s.pdf cholicystitis care plans

care plans in tabular form

1. ASSESSMENT

NURSING
DIAGNOSIS



GOAL
)

INTERVENTION

RATIONALE

IMPLEMENTATION(

EVALUATION


(1)
SUBJ :DATA
Patient said’’I
am not able to
do my daily
routine which
I was doing
normally
before due to
severe pain on
my
abdomen”’

OBJ:DATA
On assessment patients is having abdominal pain ,weakness and tiredness due to disease condition”.


Acute Pain
related to inflammation and obstruction of the gallbladder as evidenced by patient reports of right upper quadrant pain, guarding, and discomfort.



The patient will report a decrease in pain levels to a manageable level within 24 hours.










Assess patient's e level of pain and tolerance Administer prescribed analgesics as per the pain management protocol
Monitor vital signs Provide rest period between activites

Provide education on and encourage the use of non- pharmacologic pain relief techniques (e.g.,
deep breathing,
Assessment will help
to understand patients abilities to do his
activities and which will help to prioritize nursing care
Analgesics help in reducing pain and improving patient comfort
Vital signs are the
basic indicators of persons well being

Non-pharmacologic
methods can complement medication to provide more comprehensive
pain relief.

Assessment done.Patient have severe abdominal pain
Tab oxycodone 10
mg given for pain management.
Vital signs monitored every 4 th hourly Bp 130/80 HR- 87/mnt
RR- 26/mnt
Temp: 37.8 degree celscious

Education given to patients family about non
pharmacologic

The patient reports pain at a level of 3/10 or lower within 24 hours.

2. Assessment

2

Objective data
Patient”s wbc
count is increasing


Nursing
diagnosis


Risk for
Infection
related to the
presence of
inflammation
and potential
for bacterial
infection in the
gallbladder



















Goal


The patient will
exhibit no signs
of infection (e.g.,
normal WBC
count, afebrile)
by discharge.
The patient will
verbalize
understanding of
infection
prevention
measure














relaxation).


Interventions


Assess vital signs
regularly,
especially
temperature

Monitor white
blood cell (WBC)
count

Assess for signs
and symptoms of
infection (e.g.,
redness, swelling,
pus, increased
pain
)

Administer
prescribed
antibiotics

Educate the patient
and family about
signs of infection
and when to seek
medical help




Rationale


Early detection of
fever can indicate
infection, allowing
prompt intervention

Elevated WBC count
may indicate
infection; monitoring
helps in assessing the
patient's response to
treatment.

Early identification of
infection signs allows
for timely treatment.

Antibiotics help in
eradicating or
controlling bacterial
infections.

Increases the
likelihood of early
detection and
treatment of
infection.
pain relief
methods.

Implementation


Assessment
done.patient had
mild fever.temp
38.2 degree
farenheat

Wbc count is
elevated than
yesterday.todays
count is 11000

No sighns of
infection noted



Inj.Tazobactem 4.5
grm TDS started
for him.


Health education to
family given.They
are very co
operative



Evaluation


Patient
protected
from
infection as
evidenced
that the
patient
remains
afebrile and
shows no
signs of
infection
throughout
the hospital
stay.

3. (3)

Objective
data

On assessment
patient is tired
and he needs
assistance for
meeting his
basic needs.






















Self-care
deficit Self-
care deficit related to generalized
weakness secondary to liver
dysfunction as
evidenced by patient need help to go to the bathroom.







Patient will
demonstrate
Improvement in
his ability to
perform self-care
activities






















Assess the patient's
level of weakness and ability to perform ADLs (Activities of Daily Living)
Provide assistance with mobility (e.g., use of walker, cane, or assistance
from caregiver)
Implement a physical therapy program tailored to the patient's condition Assist with bathing, grooming, and dressing as needed
Provide a balanced diet and consider nutritional supplements if necessary



To establish a baseline and identify specific areas of need for assistance
Generalized weakness can increase the risk of falls; assistance helps ensure patient safety
Gradual exercise can help improve muscle strength and endurance over time
Helps maintain personal hygiene and promotes dignity and comfort
Adequate nutrition is essential for maintaining strength and overall health, which can improve self-care ability


Assessment done.patient is weak to walk and to do his daily activites.
Fall precaution implemented while ambulating the patient
Physiotherapy given by physiotherapist in frequent intervals
Assisted him for bathing and changing dress



Patient demonstrat ed increased ability to perform self-care
activities

4. 4
Objective
data

On assessment
patient cannot
eat and drink
adequately
due to
vomiting























Imbalanced nutrition less than body requirements related to impaired liver function, reduced appetite, malabsorption, and increased metabolic demands



Patient will maintain adequate nutritional status and will have energy to do his day to day activities



Conduct a thorough nutritional assessment, including dietary history, weight history, and lab values. Monitor weight and body measurements regularly.
Do dietary modification as needed
Check weight periodically
Provide health education about protein rich diet

Educate the patient and family about the importance of proper nutrition and provide resources for meal planning and
preparation

It will help to establish baseline
data for tailoring nutritional care and monitoring progress.
Collaborate with a dietitian to develop a high-calorie, high-
protein diet that is easy to digestion
Weigh is the basic indicator of nutritional status
It will help them to identify various food items.



Balanced diet provided as per the advise of dietitian
Nutritional assessment done His albumin level is low.albumin infusion given
High protein diet given as per dietions order
His weigh is 65 kg.weight checking weekly



His nutritional status improved as evidenced by increased his weight to 70 kg from 69 kg

5. Objective
Data

Patient is
asking many
questions
about his
disease and its
management



Deficient Knowledge regarding disease process, dietary
restrictions, and management plan related to lack of information or misinformation as evidenced by patient’s questions and expressed lack of understanding.
The patient will
verbalize understanding of the disease process, dietary restrictions, and management plan by discharge.

Assess the patient’s current knowledge level and understanding Provide written and verbal information about the disease process
Explain the importance of dietary restrictions and provide examples of allowed and restricted foods
Involve a dietitian to develop a personalized dietary plan


Identifying the patient's baseline knowledge helps in tailoring education to their specific needs and gaps.
Different modes of
information can enhance understanding and retention
Clear, practical information helps the patient understand and adhere to dietary changes
A dietitian can provide specialized dietary advice and meal planning, which can improve adherence and outcomes.

Assessment done.patient have poor knowledge
about disease condition.He need further education for that. Leaflets about
disease condition and its home management given in understandable language. Clear explanations
given about dietary management
Dietion seen.Advises given about dietary management


Patient gains knoweledg
e about his condition as evidenced by he
paccurately verbalizes an understandi ng of the disease process, dietary restrictions, and
manageme nt plan.