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Transcript of Chole Power Point
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CHOLECYSTECTOMY CHOLECYSTECTOMY
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INTRODUCTIONINTRODUCTION
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-- is theis the inflammationinflammation of theof the gall bladdergall bladder..
CholecystitisCholecystitis is often caused byis often caused bycholelithiasischolelithiasis (the presence of (the presence of cholelithscholeliths,,
or gallstones, in the gallbladder), withor gallstones, in the gallbladder), with
cholelithscholeliths most commonly blocking themost commonly blocking the
cystic ductcystic duct directly. This leads todirectly. This leads to
inspissationinspissation (thickening) of (thickening) of bilebile, bile, bile
stasisstasis, and secondary infection by gut, and secondary infection by gut
organisms, predominantlyorganisms, predominantly E. coli E. coli andand Bacteroides Bacteroides species.species.
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Stones in the gallbladder may causeStones in the gallbladder may causeobstruction and the accompanying acuteobstruction and the accompanying acute
attack.attack.
The patient might develop a chronic, lowThe patient might develop a chronic, low--
level inflammation which leads to alevel inflammation which leads to a
chronicchronic cholecystitischolecystitis, where the, where the
gallbladder is fibrotic and calcified andgallbladder is fibrotic and calcified and
the need to undergo surgery is advisedthe need to undergo surgery is adviseddue to the severe symptoms that are feltdue to the severe symptoms that are felt
by the patient.by the patient.
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Cholecystectomy is an operation toCholecystectomy is an operation toremove the gallbladder. Surgical removalremove the gallbladder. Surgical removal
of the gallbladder along with the stonesof the gallbladder along with the stones
has been the standard of care forhas been the standard of care for
gallstones.gallstones.
The gallbladder is not a necessary organThe gallbladder is not a necessary organ
and patients are not expected to incurand patients are not expected to incurpermanent functional impairment afterpermanent functional impairment after
its removal.its removal.
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AMERICAAMERICA PHILIPPINESPHILIPPINES
WITH A DIAGNOSIS OFWITH A DIAGNOSIS OF
CHOLECYSTITISCHOLECYSTITIS/ / CHOLELITHIASISCHOLELITHIASIS 5050--75%75% 2020--40%40%
SICKLE CELL DISEASE PATIENTS WHO SICKLE CELL DISEASE PATIENTS WHO
DEVELOPED DEVELOPED CALCULOUSCALCULOUS CHOLECYSTITISCHOLECYSTITIS 3434-- 70%70% 3030--37%37%
Statistical basis:
#1 Occurrence of CalculousCholecystitis
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LCLC OCOC
DUR ATION OF OPER ATION 64 MINUTES DUR ATION OF OPER ATION 64 MINUTES 81.4 MINUTES 81.4 MINUTES
(R ANGE: 42 TO 1(R ANGE: 42 TO 103 MINUTES) (R ANGE: 5503 MINUTES) (R ANGE: 55--125 MIN)125 MIN)
SPAN OF R ECOVERY WITHIN 24 HOUR S POST OP TOSPAN OF R ECOVERY WITHIN 24 HOUR S POST OP TO 5 DAYS POST OP5 DAYS POST OP
#2 Duration of Operation vs. R ecovery days of
LC and OC
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Anatomy and PhysiologyAnatomy and Physiology
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The gallbladder is a small, pear-
shaped pouch, non-vital organ in the
upper-right part of your abdomen(tummy) that aids in the digestive
process and stores bile produced in
the liver .
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It is divided into three sections:fundus, body, and neck. The neck
tapers and connects to the biliary
tree via the cystic duct, which then
joins the common hepatic duct to
become the common bile duct.
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The adult human gallbladder storesabout 50 mL of bile, which is
released when food containing fat
enters the digestive tract, stimulatingthe secretion of cholecystokinin
(CCK). The bile, produced in the
liver , emulsifies fats in partly
digested food.
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After being stored in the gallbladder,
the bile becomes more concentratedthan when it left the liver , increasing
its potency and intensifying its effect
on fats. Bile is made fromcholesterol, bile salts and waste
products. When these substances are
out of balance, small, hard stones
called gallstones can form.
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Gallbladder obstructedGallbladder obstructed
by gallstonesby gallstones
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DiagnosticProcedures
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Cholecystitis is usually diagnosed by a
history of presenting symptoms as well
examination findings:fever (usually low grade in uncomplicated
cases)
tender right upper quadrant +/- Murphy'ssign
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Laboratory tests CBC and liver function test)
frequently show raised hepatocellular liver
enzymes with a high white cell count (WBC).
Sonography is a sensitive and specific modality
for diagnosis of acute cholecystitis; adjusted
sensitivity and specificity for diagnosis of acutecholecystitis are 88% and 80%, respectively.
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CT scan findings are in the range of 90-95%. CT
is more sensitive than ultrasonography.
X ray of the gallbladder and biliary channels,
following the administration of a radiopaque dye,
one of the techniques of diagnostic imaging. In
oral cholecystography, the dye is ingested,
absorbed by the intestine, and concentrated by the
gallbladder, which normally appears well opacifiedin the X ray.A bnormalities (e.g., gallstones) may
be demonstrated by radiolucent areas.
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The electrocardiogram (ECG) is a graphicrecording of the electrical activity of the heart
detected at the body surface and amplified. The
ECG is of greatest use in diagnosing cardiac
arrhythmias, acute and prior myocardial
infarctions, pericardial disease, cardiac
enlargement (atrial and ventricular), and various
electrolyte disturbances and drug effects.
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Urinalysis - Laboratory examination of a sample
of urine to obtain clinical information. Most of the substances normally excreted in the urine are
metabolic products dissolved or suspended in
water.A deviation from normal in the
concentration of urinary constituents or the
abnormal presence of specific substances may
thus be indicative of bodily disorders. Changes in
urine colour, specific gravity, and volume mayalso provide evidence of a specific disease or
body injury.
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Cardiopulmonary Clearance or CP clearance is an additional diagnostic test to
rule out other disease a patient may have. It
is often used to patients who exhibit risk factors such as old age >40, gender, etc. that
may consider them as candidates for
developing such diseases affecting the heartand lungs.
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Cholangiogram or injecting of
dye during the procedure to detect
some stones
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OR
OR TECHNIQUESTECHNIQUES
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OR Techniques
There are two ways of performing acholecystectomy:
Laparoscopic (keyhole) cholecystectomyThis is the most common way of having
your gallbladder removed. The operation is
carried out using a tiny camera and surgicalinstruments that are inserted through small
incisions (cuts) in your abdomen.
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The laparoscopic approach has been
proven to be superior to conventional
open cholecytectomy because of less pain, quicker recovery, fewer
problems with incisions and better
cosmetic appearance.
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It has even been proven to be safe for
pregnant patients if certain precautions aretaken. It must be emphasized that both
laparoscopic and open cholecystectomy
may have complications such as bile ductinjury, bleeding, bile spillage, hernia,
spillage of stones, missed bile duct stones
and complications related to general
anesthesia.
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In the US and in most advanced centers
elsewhere, laparoscopic cholecystectomyhas become the gold standard. In the
Philippines, the laparoscopic approach is
slowly but surely replacing the open or conventional cholecystectomy as the
procedure of choice.
Length of hospital stay: Eighty-eight percent of the patients were discharged
within 24 hours of operation.
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Open cholecystectomy
The gallbladder is removed through onelarge cut in your abdomen. This technique
is called open surgery. It is a more
invasive operation than keyhole surgery,
you need to be in hospital for longer and
it takes longer to recover. Open surgery isa traditional approach and is rare in
modern practice.
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A traditional open cholecystectomy is a major
abdominal surgery in which the surgeon
removes the gallbladder through a 10-18 cm (4-
7 inch) incision. The surgeon will make a 5 to 7
inch incision in the upper right part of your
belly, just below your ribs. The surgeon will cut
the bile duct and blood vessels that lead to the
gallbladder. Then your gallbladder will be
removed.Open gallbladder removal surgery takes about
an hour.
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Length of hospital stay: Patients usually
remain in the hospital overnight and mayrequire several additional weeks to
recover at home.
It takes a minimum of 7 to 15 days to
complete the treatment although in some
cases, the patient can take as long as 30days to fully complete treatment.
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Instruments: The most commonly used
instruments in surgery are still thescalpel (knife), hemostatic forceps,
flexible tissue-holding forceps, wound
retractors for exposure, crushing andnoncrushing clamps for intestinal and
vascular surgery, and the curved needle
for working in depth, and additional
television to view the field if a
laparascope is used.
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Before the Procedure
Always tell your doctor or nurse:
If you are or might be pregnantWhat drugs, vitamins, and other
supplements you are taking, even
ones you bought without a prescription
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During the week before your surgery:
You may be asked to stop taking aspirin,ibuprofen (Advil, Motrin), vitamin E,
warfarin (Coumadin), and any other drugs
that make it hard for your blood to clot.Your doctor may ask you to "clean out"
your colon or intestines.
Ask your doctor on which drugs you shouldstill take on the day of your surgery.
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On the day of the surgery:
Do not eat or drink anything after midnight the night before your surgery.
Take the drugs your doctor told you to
take with a small sip of water.Shower the night before or the morning
of your surgery
Your doctor or nurse will tell you when
to arrive at the hospital.
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A.A. Open CholecystectomyOpen Cholecystectomy B. LaparoscopicB. Laparoscopic
CholecystectomyCholecystectomy
Illustration of human gallbladder undergoing LC
& OC Cholecystectomy
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After the Procedure
People usually stay in the hospital for 2
to 6 days after open gallbladder removal
but for laparoscopic it only takes 24-48hours. During that time:
The nurse will help you sit up in bed,
hang your legs over the side, and thenstand up and start to walk.
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At first you will receive fluids intoyour vein through an intravenous tube
(IV). Soon, though, the doctors and
nurses will ask you to start drinkingliquids and then eat other foods.
You will be able to begin showering
again while you are still in the hospital.
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You may be asked to wear pressure
stockings on your legs to help prevent
a blood clot from forming. These help
keep your blood circulating well.
If there were problems during your
surgery, or if you have bleeding, a lotof pain, or a fever, you may need to
stay in the hospital longer.
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DRUG
S
TUDYDRUG
S
TUDY
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Generic Name: Cefuroxime
Brand Name: Zinacef
R oute & Dosage: IV
, 750
mg30
-60
minutespre-op.
Action: anti-infective
Indication: perioperative prophylaxisAdverse R eaction: nausea & vomiting
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Nursing Considerations:
1.Check for doctor¶s order.2.Perform ST first.
3.Should not be given if positive to skin test.
4.If negativeS
T, administer it by slow IV
push.5.Inform the patient regarding possible side
effects of the drug.
6.Advise patient to report any discomfort on
the IV insertion site.7.Do not mix Zinacef with other solutions like
aminoglycosides.
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Generic Name: Gentamicin Sulfate
Brand Name: Gentamicin, Alcomicin
Route &D
osage:IV
, 80 mg/ ampuleAction: anti - infective
Indication: prophylaxis for GIT
surgery/procedureAdverse Reaction: headache, dizziness,
nausea, and vomiting
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Nursing Considerations:
1. Always check for doctor¶s order.2. Perform Skin Test.
3. Do not give if positive to skin test.
4. If negative to skin test, administer it byslow IV push.
5. Inform the patient about the side effects of
the drug.
6. Advise patient to report any discomfortafter administering the drug.
7. Do not mix with other drugs for
parenteral use.
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Generic Name: Ampicillin
Brand Name: Omnipen
Route & Dosage: IV, 1g./amp
Action: anti - infectiveIndication: prophylaxis for GIT
surgery/procedure
Adverse Reaction: headache, dizziness,
nausea, and vomiting
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Nursing Considerations:
1. Always check for doctor¶s order.
2. Perform Skin Test.3. Do not give if positive to skin test.
4. If negative to skin test, administer it by
slow IV push.
5. Inform the patient about the side effects
of the drug.
6. Advise patient to report any discomfort
after administering the drug.7. Do not mix with other drugs for
parenteral use.
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Generic Name: Clomipramine HCL
Brand Name: Placil
Route & Dosage: PO, 10mg tab
Action: anti- infammatory
Indication: for chronic pain
Adverse Reaction: headache, dizziness,malaise, dry mouth
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Nursing Considerations:
1. Check for doctor¶s order
2. Not to be given to patients with
hypertension3. Inform the patient about the
adverse effects.
4. Instruct to take it w/meals toavoid GI irritation.
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Generic Name: K etorolac
TromethamineBrand Name: Toradol
Route & Dosage: IM, 30mg/ampAction: anti ± inflammatory, analgesic
Indication: short ± term management of
moderate to severe pain.Adverse Reaction: headache, dizziness,
nausea, and vomiting, flatulence, sedation.
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Nursing Considerations:
1.Always check for doctor¶s order.
2. Perform Skin Test.3. Do not give if positive to skin test.
4. Do not mix w/ morphine sulfate.
5. Give IM slowly and deeply into the
muscle.6. Protect the injection site from light.
7. Inform the patient about the side effects of
the drug.8.Advise patient to report any discomfort
after administering the drug.
9. Do not mix with other drugs for parenteral
use.
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Generic Name: Lidocaine HCL
Brand Name:X
ylocaine,X
ylocard
Route & Dosage: IV, 30mg./amp
Action: produces anesthesia, increases pain ± threshold
Indication: anesthesia for surgery.
Adverse Reaction: headache, dizziness,nausea, and vomiting, flatulence,
sedation
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Nursing Considerations:1. Do not add lidocaine to blood transfusion.
2. Do not mix with epinephrine if patient needs epinephrine.
3. Reduce IV bolus dosage for patients 70 y/o, with CHF, or
liver disease.
4. Note for any hypersensitivity to amide-local anesthetics.
5. Document CNS status.
6. Monitor liver, and renal function studies.
7. Closely watch for adverse effects involving respiratory
depression.
8. Monitor if malignant hyperthermia develops
(tachycardia-earliest sign).
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NUR SING CAR E NUR SING CAR E
PLANPLAN
Assessment Nursing Planning Interventions Rationale Evaluation
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Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
S ² ´ masakit yungnaoperahan sa akin,µ asverbalized by the
patient.With a pain scale of 7/10
O ² difficulty of movingas manifested by facialgrimace
(+) muscle guarding
T: 36.9 RR-19 bpmPR-90 bpmBP-130/09mmHg
Acute pain related tooperation done (opencholecystectomy) as
evidenced by surgicalincision.
After 3 hours of nursing intervention,the patient will report
relieve of pain from7/10 to 3/10.
1. Observe anddocument the location
and character of pain,2. Promote bed rest,
allowing patient toassume comfort
position.3. Control
environmentaltemperature.4. Encourage use of
relaxation techniques(e.g. deep ² breathingexercises, diversionalactivities, guidedimagery).5. Administer analgesicsas ordered.
6. Observe non-verbalcues of pain for patientswho cannot
communicate well.7. Provide comfort
measures (e.g.repositioning,
assurance, and nurse·spresence).8. Make time to listen
and maintain frequentcontact with the patient.
- assists in differentiatingcause and severity of
pain.- bedrest in low-
fowler·s positionreduces intra-abdominal
pressure; thus, reducespain.
- cool surroundings aidin minimizing dermaldiscomfort.
- promotes rest,redirect attention, andmay enhance coping.-relief of pain facilitatescooperation with othertherapeutic regimen.-Observations are not
always congruent withverbal description; thusit will serve as
indicators of pain fornurses· assessment.
-it promotes non-pharmacological pain
management-helpful in alleviatinganxiety and refocusing
attention w/c canrelieve pain.
After 3 hours of nursing intervention,
the patient hadreported relieved of pain from 7/10 to 3/10.
Assesment Nursing Diagnosis Planning Interventions Rationale Evaluation
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g g g
S- ´Nasusuka ako satuwing maiisip ko naooperahan ako,µasverbalized by the
patientO- (+) vomiting (5x) in6 hours(+) body weakness(+) pallor
Poor skin turgor(+) dry skin(+) dry mouthT: 37.6
PR: 98bpmRR: 22bpmBP: 140/90mmHg
Fluid Volume Deficientrelated to vomiting asmanifested by poorskin turgor, pallor, dryskin, body weakness,and dry mouth
After 4 hours of nursinginterventions, thepatient will maintainadequate fluid volume
as evidenced by goodskin turgor, regain bodystrength, (-) pallor, (-)dry mouth, and (-) dryskin.
1. Maintain accuraterecord of I&O.2. Perform frequentoral hygiene.
3. Increase fluid intake.4. Encourage patient toeat foods with fluidcontent.5. Administer anti-
emetics as ordered.6. Limit intake of alcohol and caffeinatedbeverages.
7. Assess vital signs(note: pulse andrespiration may be
elevated in fluid volumedeficit).
8. Administer fluids andelectrolytes asprescribed.
(hypotonic/hypertonicdepending on the typeof dehydration present)
-Provides informationabout fluid status/circulating volume andreplacement needs.
-decreases dryness of oral mucousmembranes, reducesrisk of oral bleeding.-promotes hydration
-relieves thirst andminimizes the use of parenteral replacement.-reduces nausea and
prevents vomiting.-These beverages areavoided due to its
diuretic effect.-to evaluate degree of
fluid deficit.-to correct/replace fluidlosses abruptly.
After 4 hours of nursinginterventions, thepatient had maintainedadequate fluid volume
as evidenced by goodskin turgor, regainedbody strength, (-) pallor,(-) dry mouth, and (-)dry skin.
Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
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S- ´Pwede bang maulit
ang sakit ko?µasverbalized by thepatient
O- Frequently asking
questions about his/hercondition and dischargeneeds with worriedgaze.VS taken as followsT: 37.0 PR: 80bpmRR: 19bpm
BP: 120/80mmHg
Deficient knowledge
related to condition,prognosis, treatment,discharge needs and
self-care as evidenced
by frequent asking withworried gaze.
After 3 hours of nurse-
patient interactions, thepatient will be able toverbalize understanding
of disease process,
prognosis, proper diet,and potentialcomplications.
1. Determine blocks to
learning (languagebarrier and literacyskills).
2. Review disease
process/ prognosis, andencourage questioningabout the topic.3. Review drug regimen,possible side effects.4. Determine client·smost urgent need fromboth clients·s and
nurse·s view point.
5. Use short simplesentences and concepts.
Repeat and summarizeas needed.
6. Instruct patientregarding proper dietand foods to be avoided
like fatty foods, wholemilk, ice cream butter
etc.7. Include theAffective goals (e.g.reduction of stress).8. Provide explanations/
reasons for testsprocedures and
preparation needed.
-to identify factors that
may hinder the learningprocess.-provides knowledge
base from which patient
can make informedchoices.-Gallstones often recur.Necessitating long termtherapy.-to establish priorities inconjunction w/ client·sneed.
-to facilitate fast
learning.-Prevents/ limits
recurrence of gallstoneformation
-to develop/ formulatelearning objectivesfaster.
-information candecrease anxiety.
After 3 hours of nurse-
patient interactions, thepatient had verbalizedunderstanding of
disease process,
prognosis, potentialcomplications, andproper diet by restatingthe teachings givenearlier.
Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
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S- ´Wala akong ideya
kung anong gagawin kosa sugat ko,µ asverbalizes by the
patient.O- Anxiety and fear of handling thedressing/incision site.VS taken as followsT: 37.1 PR: 85bpm
RR: 19bpmBP: 120/80mmHg
Knowledge Deficient
related to condition andself-care as evidencedby fear of handling the
dressing/incision site.
After 3 hours of nurse-
patient interactions, thepatient will be able toverbalize understanding
of the therapeuticregimen and will be ableto demonstrate dressingchange and cleaning of the incision site.
1. Review disease
process, surgicalprocedure.2. Demonstrate care of
incision or dressing.3. Determine client·sability/readiness andbarriers to learning.4. Identify outcomes(results) to be achieved.5. Involve the client/s by
using age-appropriatematerials tailored to
client/s literacy skills.6. Provide positivereinforcement.
7. Provide writteninformation/ guidelines
and self-learningmodules for client torefer to as necessary.
8. Review activity
limitations depending onindividual situation.
-provides knowledge
base on which patientcan make informedchoices.
- promotesindependence of careand reduce risk of having infection.- individual readinessvaries at this time(Physically, emotionally,
and mentally).-to meet learner·s (not
instructors) needspromptly.-to facilitate easy
learning/recall.-encourage continuation
of efforts.-it allows clients/s toproceed at own pace
and establishes
independency.- Resumption of usualactivities is normally
accomplished w/in 4-5weeks.
After 3 hours of nurse-
patient interactions, thepatient had verbalizedunderstanding of the
therapeutic regimen anddemonstrated dressingchange and cleaning of the incision site.
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GROUP IIIGROUP III
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GROUP IIIGROUP III
BSNBSN 3B23B2--55
REMIGIOREMIGIO,, ANGELIEANGELIEA.A.
SANTOSSANTOS. DIANNE. DIANNE
VEQUISOVEQUISO,, ELIZABETHELIZABETH
RILLERARILLERA,, ZARAHZARAH MAEMAERIVERARIVERA, MATT , MATTARNOLDARNOLD
FACELOFACELO,, JENNYLYN JENNYLYN
TEVESTEVES,, CARLOCARLO
KAWIKAWI,, KARENKARENVALEZAVALEZA,, ELAINEELAINE
SEBASTIAN, MA.SEBASTIAN, MA. JUBELLE JUBELLE
BOLOSANBOLOSAN,, OLIVEROLIVER