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A Subjective data: N Impaired skin Within 2 hours of 1. Keep the surgical incision site clean and dry, prevent GOAL MET
P ³Gilok gamay ang U integrity related nursing intervention: further infection and stimulate circulation to surrounding
R samad, pero wala T to altered biliary areas. Within 2 hours of nursing
na kayo syay sakit´ drainage after
I R h Maintain skin Rationale: | 



   intervention:
as verbalized by the surgical
L I intervention as integrity by keeping  

   

 

patient
T evidenced by the skin intact, dry      



   

  X Skin kept clean, dry
11, Objective data: I the CBD drain and free from signs and intact; with no
2011 O tube in place for infection such as  noted signs of redness
-Post 2. Encourage patient to engage in hygienic practices like
N several days redness and and infection; afebrile
cholecystectomy last secondary to sponge bath and daily grooming. Rationale:   
5:00 February 25, 2011 A increase body 
 
 
   

 
  
choledocholithia
P.M. - with a CBD drain L temperature          
     
 
sis X Demonstrated proper
tube draining -     
M  hand washing before
greenish fluid (bile) Rationale:
E h Demonstrate at 3. Maintain appropriate moisture environment for touching the dressing
into a cellophane particular wound.
T After undergoing least one way on and the wound, and
bag attached to the Rationale:              
A cholecystectomy how to manage verbalized
end of the tube; the 
   
 
B , the patients proper skin care understanding of the
tube is inserted to a 
O usually have a such as practicing importance of taking
small stab wound in 4. Reposition client on regular schedule, do not position
L T-tube or proper hygiene by the patient on site of impairment. daily bath
right upper quadrant
I Common Bile taking a bath every Rationale: |    
   

    
of the abdomen
C Duct (CBD) day and washing 

   
  
  
which is about half 
draining tube for hands thoroughly
an inch in legth 5. Encourage early ambulation and mobilization and assist
P several days to before making any
- a diagonal 3.3 in range-of-motion exercises.
A ensure that the contact with the
inches scar at right Rationale:    

    
T bile drainage is incision and the
 
  
upper quadrant of
T not obstructed. dressing
the abdomen due to
E A T-tube is used 6. Teach the patient on the importance of skin and
previous surgery;
R to drain bile after measures to maintain proper skin functioning.
dark brown in color Rationale: |    
     
  
with visible marks of N cholecystectomy
   

  
stitches on the side until swelling of 
- with a dressing at the duct 
the incision area of subsides. 7. Assist the client in understanding and following medical
regimen and developing program of preventive care and
the tube that is 4
Source: daily maintenance.
inches in length and Rationale: 
       
   
7.5 inches in width; Understanding
  
dressing is dry and medical-surgical

intact nursing by Linda 8. Increase tissue perfusion by massaging around affected
S. Williams and area.
Paula D. Rationale:       
 !


Hopper, 3rd    




   

Edition, 2007, p.
9. Assess the patient¶s nutritional status.
741 Rationale: 
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10. Encourage intake of foods, vitamins, and minerals like


iron supplement and vitamin C.
Rationale: #     
     
 
      
             
 
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11. Allow patient to demonstrate at least one management
of skin care.
Rationale: |