GCP NCPs 1. 2. 3. 4. 5. 6. 7. 8.

Acute pain related to biliary colic in the right upper quadrant Acute pain related to post operative wound on the right lower quadrant of the abdomen Ineffective airway clearance related to increased tracheobronchial secretions Ineffective breathing pattern related to bronchospasm Hyperthermia related inflammatory process Imbalanced nutrition: less than body requirements r/t decreased food intake Impaired skin integrity related to surgical wound on the right lower quadrant of the abdomen Sleep pattern disturbance related to pain secondary to post operative wound on the right lower quadrant of the abdomen / Sleep pattern disturbance related to frequent coughing 9. Impaired Physical Mobility related to the experience of pain on wound site at the right lower quadrant of the abdomen./ Activity intolerance related to imbalance between oxygen supply and demand 10. Noncompliance 11. High risk for infection related to inadequate primary defense secondary to post-operative wound on the right lower quadrant of the abdomen 12. High risk for infection related to accumulation and stasis of fluids in the respiratory tract

CUES

NURSING DIAGNOSIS 1. Chronic Pain related to obstruction as evidenced by presence of biliary colic

OBJECTIVES Short-term: At the end of 30 minutes, patient will be able to: Verbalize willingness to cooperate in the planned interventions Verbalize understanding of the importance of relaxation skills and diversional activities demonstrate nonpharmacolo gical methods that provide relief such as deep breathing excercises and splinting

INTERVENTIONS Independent: Observe and document location, severity (0-10 scale), and character of pain (e.g., steady, intermittent, colicky).

RATIONALE Assist in differentiating cause of pain, and provides information about disease progression/resolut ion, development of complications, and effectiveness of intervention. Severe pain not relieved by routine measure may indicate developing complications/nee d for further intervention. Bed rest in lowfowlers position reduces intraabdominal pressure; however, client will naturally assume least painful position. Cool surrounding aid minimizing dermal discomfort. Promotes rest, redirects attention, may enhance coping.

EVALUATION Short-term: At the end of 30 minutes, patient will be able to: Verbalize willingness to cooperate in the planned interventions Verbalize understanding of the importance of relaxation skills and diversional activities demonstrate nonpharmacologi cal methods that provide relief such as deep breathing excercises and splinting

Note response to medication, and report to physician if pain is not relieved.

Promote bed rest, allowing client to assume position of comfort.

Long term: At the end of 8 hours, the patient will be able to: follow prescribed pharmacologic regimen as ordered by the physician report decrease pain using pain scale.

Control environmental temperature. Encourage use of relaxation techniques; e.g., guided imagery, visualization, deepbreathing exercises. Provide diversional activities. Make time to listen to and maintain frequent contact with client.

Long term: At the end of 8 hours, the patient will be able to: follow prescribed pharmacologic regimen as ordered by the physician report decrease pain using pain scale.

Helpful in alleviating anxiety and refocusing attention, which can relieve pain.

Collaborative: Prepare for procedure: Open surgical intervention

Cholecystectomy may be indicated because of the size of stones and degree of tissue involvement/prese nce of necrosis. To determine baseline data and significant abnormalities especially in the patients breathing pattern. To confirm presence of pain and the patients response to it. Short term: At the end of 30 minutes nursing interventions, the patient was able to: report pain is controlled verbalize understanding of the importance of relaxation skills and diversional activities

2. Acute pain related to post operative wound on the right upper quadrant of the abdomen

Short term: At the end of 30 minutes nursing interventions, the patient will be able to: Report pain is controlled Verbalize understanding of the importance of relaxation skills

Independent: Monitor v/s

Observe nonverbal cues for pain to evaluate pain behavior

and diversional activities

Long term: At the end of 4 hours of nursing intervention, the patient will be able to: Verbalize method/s that provide relief Initiate the use of relaxation techniques when in pain Use diversional activities as indicated Follow prescribed regimen

Provide comfort measures such as positioning and splinting Encourage the use of relaxation techniques such as deep breathing Encourage ambulation as tolerated with adequate rest periods in between Encourage verbalization of pain as it begins

To provide relief from pain and to promote circulation To calm the patient and to ease the pain To decrease possibility of postoperative complications To reduce anxiety and fear and to provide immediate intervention

Short-term pbjectives were completely met.

Collaborative:

Long term: At the end of 4 hours of nursing intervention, the patient was able to: Verbalize method/s that provide relief Initiate the use of relaxation techniques when in pain Use diversional activities as indicated Follow prescribed regimen Long-term objectives were completely met.

3. Ineffective airway clearance related to increased tracheobron chial secretions

Short term: At the end of 15 30 mins of nursing intervention, the patient will be able to: verbalize willingness to cooperate in the planned interventions verbalize understanding on the importance of maintaining clear airways readily clear or expectorate secretions Long-term: At the end of 4 8 hours of nursing interventions, the patient will be able to: demonstrate reduction of congestion maintain airway patency demonstrate improved respiratory status

Independent: Keep environment free from allergens and irritants according to individual situation. Elevate level of the bed and encourage proper positioning as tolerated. Encourage pursedlip breathing and coughing exercises as tolerated. Encourage warm fluid intake. Observe for improvements in symptoms or any further respiratory distress.

To lessen precipitators that may trigger onset of signs and symptoms thus, exacerbating the condition To take advantage of gravity decreasing pressure on the diaphragm To provide means to control dyspnea Warm fluids helps decrease viscosity of secretions To initiate immediate nursing interventions as needed

Short term: At the end of 15 30 mins of nursing intervention, the patient was able to: verbalize willingness to cooperate in the planned interventions verbalize understanding on the importance of maintaining clear airways readily clear or expectorate secretions Short term objectives were completely met. Long-term: At the end of 4 8 hours of nursing interventions, the patient was able to: demonstrate reduction of congestion maintain airway patency demonstrate improved respiratory status Long term objectives were completely met. Short- term:

Collaborative:

4. Ineffective

Short- term:

Independent:

breathing pattern related to bronchospa sm

At the end of 15 30minutes nursing intervention, the patient will be able to: verbalize willingness to cooperate in the planned interventions verbalize understanding on the importance of maintaining normal breathing pattern enumerate strategies to maintain normal breathing pattern.

Monitor respiratory status and oxygen saturation for abnormalities Moderately elevate head of bed or have the patient position as indicated and as tolerated. Allow patient to slowly and deeply breathe or to do pursed lip breathing. Encourage warm or tepid oral fluid intake. Maintain calm environment and attitude when dealing with the client and significant others. Encourage patient to follow indicated diet and amount of fluid per day.

To ensure early detection and to perform early interventions to prevent complications To promote ease and to maximize inspiration

To provide means to cope with and to control dyspnea To decrease bronchospasm To prevent emotional stress which can change the breathing pattern of the patient. To avoid complications and over exhaustion of the body which has a negative effect on the breathing pattern.

At the end of 15 30minutes nursing intervention, the patient was able to: verbalize willingness to cooperate in the planned interventions verbalize understanding on the importance of maintaining normal breathing pattern enumerate strategies to maintain normal breathing pattern. Short term objectives were completely met.

Long - term: At the end of 8 hours nursing intervention, the patient will be able to: demonstrate strategies to maintain normal breathing pattern establish a normal respiratory pattern manifest improvements in respiratory status Short term: After 2 hours of nursing intervention , the patient will be able to: verbalize understanding of the causative factors verbalize willingness to follow needed interventions Long term: After 8 hours of nursing interventions, the patient will be able to: demonstrate

Collaborative:

Long - term: At the end of 8 hours nursing intervention, the patient will be able to: demonstrate strategies to maintain normal breathing pattern establish a normal respiratory pattern manifest improvements in respiratory status Long-term obhectives were completely met. Short term: After 2 hours of nursing intervention , the patient was able to: verbalize understanding of the causative factors verbalize willingness to follow needed interventions Short-term objectives were partially met. Long term: After 8 hours of nursing interventions, the patient was able to:

5. Imbalanced nutrition: less than body requirement s r/t decreased food intake

Independent: Assess total daily food intake. Encourage and remind patient to follow indicated diet. Promote pleasant, relaxing environment and at the same time prevent unpleasant odors and sights. Emphasize importance of wellbalanced, nutrition intake. Provide information regarding individual nutritional needs. Provide rest periods. Encourage patient to follow indicated limits

To reveal possible cause of malnutrition. To ensure conformity of the diet suitable for the patients condition to improve nutritional status. To increase appetite and enhance food satisfaction. To promote wellness for the long-term circumstances.

To save energy

consumption of nutritious food as indicated to meet bodily demands. show improvements on her laboratory values and on her overall strength

on activities.

In order to avoid over usage of energy and to decrease bodily demands

demonstrate consumption of nutritious food as indicated to meet bodily demands. show improvements on her laboratory values and on her overall strength Long-term objectives were partially met. Short term: At the end of 1 hour nursing intervention, the patient was able to: Verbalized positive feeling regarding the post op wound. Report understanding on the needed wound care. Verbalize the importance of maintaining health diet. Short-term objectives were completely met. Long term: At the end of 48hours nursing intervention, the patient was able to: Participate in the treatment regimen Verbalizes increased selfesteem Demonstrate increased ability to manage situation Long-term objectives were completely met. Short term: After 4 hours of nursing intervention, the patient was able to: Verbalize accurate knowledge of condition and understanding of treatment regimen

6. Impaired skin integrity related to surgical wound on the right lower quadrant of the abdomen

Short term: At the end of 1 hour nursing intervention, the patient will be able to: Verbalized positive feeling regarding the post op wound. Report understanding on the needed wound care. Verbalize the importance of maintaining health diet.

Independent: Monitor post-op site, drains and surrounding area. Change dressing PRN effectively. Keep areas of wound free from discharges taking note of the amount, odor, appearance and degree of pain experienced by the patient. Encourage patient to maintain optimum nutrition and hydration. Teach patient proper hygiene practices. Encourage patient to perform techniques such as splinting when moving. Collaborative:

Monitoring can lead to early detection of abnormalities and any delayed healing on the site. To maintain cleanliness on wound site. To promote healing and to detect signs of exacerbation f the wounds condition.

To promote wound healing. For patient to independently take care of her wound. To reduce pain and prevent complications.

Long term: At the end of 48hours nursing intervention, the patient will be able to: Participate in the treatment regimen Verbalizes increased selfesteem Demonstrate increased ability to manage situation

7. Noncomplia nce related to

Short term: After 4 hours of nursing intervention, the patient will be able to: Verbalize accurate knowledge of condition and understanding of treatment regimen

Independent: Determine who (e.g., client, SO, other) manages the medication regimen and whether individual knows what the medications are and why they are prescribed. Identify factors that interfere with taking

To determine reason for alteration/disregard of therapeutic regimen/instruction s

To determine reason for

 Verbalize commitment to mutually agreed upon goals and treatment plan

Long term: After 8 hours of nursing intervention, the patient will be able to: Access resources appropriately Demonstrate progress toward desired outcomes/goals.

medications or lead to lack of adherence (e.g., depression, active alcohol/drug use, low literacy, lack of support, and lack of belief in treatment efficacy). Assess availability/ use of support systems and resources.

alteration/disregard of therapeutic regimen/instruction s

Short-term objectives were partially met. Long term: After 8 hours of nursing intervention, the patient was able to: Access resources appropriately

To determine reason for alteration/disregard of therapeutic regimen/instruction s To promote wellness

Long-term objectives were partially met.

Stress importance of the clients knowledge and understanding of the need for treatment/medicatio n, as well as consequence of choices. Suggest using a medication reminder system . Provide support systems and encourage client to continue positive behaviors. Independent: Monitor vital signs.

These have been shown to improve client adherence by a significant percentage To reinforce negotiated behaviors

8. High risk for infection related to inadequate primary defense secondary to postoperative wound on the right lower quadrant of the abdomen

Short term: A the end of 1 hour of nursing intervention, the patient will be able to: Verbalize understanding of individual causative/risk factors. Identify intervention to prevent or reduce the risk of infection. Understand the importance of keeping the post-op wound dry and clean. Long term: At the end of 4-8 hours of nursing intervention, the patient will be able to: Demonstrate techniques to prevent wound infection

Monitor signs/symptoms of infection Encourage fluids Encourage intake of food rich in Vitamin C

Monitor Medical Regimen compliance Teach proper hygiene practices

To monitor changes especially in the temperature, that may be indicative of infection. To facilitate early detection and thus, provide immediate intervention. To maintain adequate hydration. Vitamin C helps on wound healing thus, decreasing the risk for infection Vitamin C is also known for boosting ones immune system. To reduce possibility of resistant strains. To reduce the recurrent infection; to deter the spread of microorganism.

Short term: A the end of 1 hour of nursing intervention, the patient was able to: Verbalize understanding of individual causative/risk factors. Identify intervention to prevent or reduce the risk of infection. Understand the importance of keeping the postop wound dry and clean. Short-term objectives were completely met. Long term: At the end of 4-8 hours of nursing intervention, the patient was able to: Demonstrate techniques to

Collaborative:

 Cooperate during procedures to reduce infection of the wound. Maintain afebrile status. Report unusual drainage and redness on the site.

prevent wound infection Cooperate during procedures to reduce infection of the wound. Maintain afebrile status. Report unusual drainage and redness on the site. Long-term objectives were completely met. Short term: A the end of 1 hour of nursing intervention, the patient was able to: verbalize understanding of individual causative/risk factors. identify interventions to prevent or reduce the risk of infection. understand the importance of decreasing congestion and stasis of fluids in the respiratory tract. Short-term objectives were completely met. Long term: At the end of 4-8 hours of nursing intervention, the patient was able to: demonstrate techniques to prevent infection cooperate during procedures to prevent occurrence of infection. maintain afebrile status. Long-term objectives were completely met.

9. High risk for infection related to accumulatio n and stasis of fluids in the respiratory tract

Short term: A the end of 1 hour of nursing intervention, the patient will be able to: verbalize understanding of individual causative/risk factors. identify interventions to prevent or reduce the risk of infection. understand the importance of decreasing congestion and stasis of fluids in the respiratory tract. Long term: At the end of 4-8 hours of nursing intervention, the patient will be able to: demonstrate techniques to prevent infection cooperate during procedures to prevent occurrence of infection. maintain afebrile status.

Independent: Monitor vital signs.

To monitor changes especially in the temperature, that may be indicative of infection To facilitate early detection and thus, provide immediate intervention To lessen precipitators that may trigger onset of signs and symptoms thus, exacerbating the condition. Vitamins and minerals helps on wound healing and in boosting ones immune system thus, decreasing the risk for infection. Proper positioning facilitates drainage of the accumulated fluids in the respiratory tract. To control the disease process thus, preventing further complications that may lead to infection.

Monitor signs and symptoms of infection. Keep environment free from allergens and irritants according to individual situation.

Encourage intake of nutritious food especially those which are rich in vitamins and minerals.

Encourage proper positioning as tolerated.

Encourage maintenance and compliance to medications.

Collaborative: