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NURSING CARE PLAN
ON
LAPROTOMY.
SUBJECT: ADVANCE NURSING PRACTICE
SUBMITTED TO: SUBMITTED BY:
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SUBMITTED ON: 15/07/2013
1. BIOGRAPHIC DATA:
Name : Mr. Sushanth
Age : 34 years
Sex : Male
Address :Ratangarh
MRD No. : 278402
Education : 10th standard
Occupation : Driver (auto)
Income : Rs. 4000
Marital Status : Married
Religion : Hindu
Mother tongue : Kannada
Language known : Kannada
Ward : Post-Operative Ward
Date of admission : 10.07.2013
Diagnosis : Intestinal Obstruction
Date of surgery : 15.07.2013
Type of anaesthesia : General anaesthesia
Operation done : Laparotomy
Name of the surgery: resection of part of ascending colon and anastomosed
to transverse colon.
2. HISTORY COLLECTION:
Chief complaints:-
- Constipation- 3-4 days
- Edema (pedal)
- Fever- 2-3 days
Present history of illness:-
Medical- pain was apparently normal 9 days back when he developed
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pain abdomen. Pain was in constricting type on & off.
Due to this reason he came to Victoria Hospital for treatment
and got admitted on 08.02.2010 and was posted for surgery.
Surgical- Laparotomy
Past history of illness:-
Medical- there is no any history of any medical illness, except
occasional cough and cold.
Surgical- there is no history of any surgery done.
Personal Habits:-
Habits – Smoker, 2 cigarettes per day and
Alcohol - occasionally
Diet- he takes a mixed diet, and eats two meals per day.
Sleeping habits- regular, 5-6 hours per day, but the last 2-3 days he is
not able to sleep due to abdominal pain.
Hobby- hanging out with his friends.
Bowel and Bladder habits- urinate 5-6 times per day and the bowel
pattern is regular, except the last 3-4
days he is having constipation.
Socialization- he is a socialise person and a loving person.
Family history:-
34 yrs
27
yrs
5
yrs
3
yrs
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There is no any history of any hereditary disease like HTN, DM, asthma, epilepsy or seizures
in the client’s family. The client is married to his wife and has two children, one son and one
daughter. All of them are enjoying a good and healthy life.
Sl
no.
Name Age Qualification/
Occupation
Relation to
Mr.sushanth.
Health status
1. Mr.sushanth. 34 yrs 10th standard Client unhealthy
2. Mrs.srinidhi 28 yrs 5th standards Wife Healthy
3. Ms. Sneha. 5 yrs 1st standards Daughter Healthy
4. Mast.sunil. 3 yrs - Son Healthy
Socio- economic status:-
Condition of the house- the client lived in his own house with his
family, which is kaccha with two small rooms including the kitchen. They used stove for
cooking. The house is supplied with electricity.
Water supply- water supply is from the corporation.
Drainage system- closed drainage system.
Surrounding environment- their surrounding environment is unhealthy.
Economic status- the client is the only source of income in their family,
his monthly income is Rs.4000 per month.
3. PHYSICAL EXAMINATION:
Vital signs:-
Temperature : 1000 F
Pulse : 98 beat per minute
Respiration : 22 per minute
Blood Pressure: 130/80 mmHg
Height and weight:-
Height: 168cm
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Weight: 65 kg
General appearance:-
Constitution : Thin
State of nutrition : Poor
Personal appearance: Normal
Posture : Normal
Skin and hair : dark complexion
Emotional state : Anxious
Co-cooperativeness: cooperative
HEAD TO FOOT EXAMINATION:-
Head:
Skull - has no abnormalities noted.
Hair - black hair, hair distribution normal
Movement of head- has full range of movement
Fore head - no scar or lesion noted
Face - anxious looking
Eyes:
Eye brows - equal and even distribution
Eye lids - no lesion or scar noted.
Lacrimation - clear fluid expression
Conjunctiva- appears pale and clear
Sclera - appears white
Cornea - appears moist
Irish pupil - appears round and central in the sclera.
Pupil - PERRLA
Ears:
Appearance- no mass or lesion noted
Discharge - None
Hearing - normal
Lesion - none
Nose:
Appearance - no septum deviation, Ryle’s tube present on the left nostril.
Discharge - none
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Patency -both nostrils are patent
Sense of smell- good
Mouth and throat:
Lips - dry
Tongue - coated tongue
Teeth - yellowish in colour
Gums - brownish black
Buccal mucosa- no lesion and ulceration
Tonsil - not palpable
Taste - abnormal
Neck:
General appearance- normal
Lymph nodes - not palpable
Thyroid glands - not palpable
Cysts and tumour - absent
Chest:
Inspection- size and shape are normal
Palpation- no local swelling noted
Auscultation- S1S2 heard.
Abdomen:
Inspection- normal in shape and size, drainage on the right side present. An
incision on the lower abdominal region. No redness and swelling noted
Palpation- soft, no organomegally
Percussion- tenderness present
Auscultation- peristalsis movement present, bowel sound absent.
Spine and back:
Spine and curvature- no lordosis or kyphosis noted.
Movement - all movement are normal
Tenderness - no tenderness noted
Genitalia:
Normal. Urinary catheter present. No discharge noted or observed.
Upper and lower extremities:
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Upper- normal movement, no lymph node enlargement noted
Lower- normal anatomically.
Skin:
Colour of skin- dark complexion
Edema- pedal edema present
Moisture- dry
Turgor- moderate
SYSTEMIC ASSESSMENT:-
Nervous system:
Conscious- client is conscious
Orientation- oriented to time, place and person.
Obeys commands- yes, client obeys commands.
Cardiovascular system:
S1- present
S2- present
S3- absent
S4- absent
Murmur- absent
Respiratory system:
Inspiration & expiration- present
Respiration rate- 22 per minute
Ronchi/ wheezing- present
Gastro-intestinal system:
Peristalsis movement- present
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Bowel pattern- irregular, constipated for the last 3 to 4 days.
Organomegally- absent
Urinary system:
Frequency- 5 to 6 times per day normally
Burning micturation- absent
Catheterization- present; Input = 1500ml, Output = 2200ml
Urine colour- dark straw colour
4. INVESTIGATION:
Sl
no.
Investigation Patient’s value Impressi
-on
Normal value
1.
Blood Test
Complete blood
count-
Hb= 11.2 g/dl
Total WBC= 11,000cells/cmm
Neutrophil=60%
Lymphocytes=35%
Eosinophils=4%
Monocytes=5%
Basophil=01%
ESR=15mm
Platelet count=3lac/L
RBS= 68mg/dl
Anaemic
Infection
Normal
Normal
Infection
Normal
Normal
Infection
Normal
Low
Hb= 14-16.5 g/dl
WBC= 5-10,000cells/cmm
Neutrophil= 47-63%
Lymphocytes=24-40%
Eosinophils=0-3%
Monocytes=4-9%
Basophil=0-2%
ESR=0-9mm
Platelet count=1.5-4lac/L
RBS= 70-120mg/dl
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2.
3.
Electrolyte
X-ray
Serology
Sodium= 144mmmol/L
Potassium=4.6mmol/L
Chlorine=107mmol/L
Serum creatinine=0.8mg/dl
Serum BUN=33mg/dl
No abnormality detected
Hbs Ag= non- reactive
HIV= non reactive
Normal
Normal
Normal
Normal
High
Normal
Normal
Normal
Sodium=135-145mmol/L
Potassium=3.5-5.0mmol/L
Chlorine=97-107mmol/L
Serum creatinine=0.7-1.4mg/dl
Serum urea=8-20 mg/dl
-
Negative
5. MEDICATION:
Sl
no
Medication Dose,
route &
time
Action of drug Side effect Nursing
responsibility
1.
2.
Inj. Omnatax
Inj. Metrogyl
1gm
IV
BD
100ml
IV
It is active against gram
–ve organisms and
betalactamase
producing organisms. It
is active against
pseudomonas,
anaerobes, and
spirochaetes.
A direct acting
trichomonocide and
amebicide that works at
Nausea, skin rash,
drug, fever,
diarrhoea, pruritis,
local reaction and
pain,
thrombocytopenia
and luekopenia.
Headache, vertigo,
seizures, abdominal
cramping, nausea,
- check vital signs.
- follow strictly the
five rights.
- monitor closely the
patient for any side
effect of the drugs
given.
-observe the site of
injection carefully.
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APPLICATION OF THEORY
Name : Mr. Sushanth.
Age : 34 years
Sex : Male
Ward : Post-Operative ward
Present compliant : - Pain in incision site
- Constipation- 3-4 days
- Edema (pedal)
- Fever- 2-3 days
Diagnosis : Intestinal Obstruction
3.
4.
Inj. Rantac
Inj. Tramadol
TDS
50mg
IV
BD
50mg
IV
BD
both intestinal and extra
intestinal sites.
Competitively inhibits
action of histamine on
the H2 at receptor sites
of parietal cells
decreasing gastric acid
secretion.
Weak agonist at opiod
receptors especially
receptors.
rash, constipation,
anorexia.
Vertigo, malaise,
headache, blurred
vision, jaundice,
burning and itching
at the injection site.
Nausea, vomiting,
dizziness, sweating,
stupor, psychiatric
reaction
check vital signs.
- follow strictly the
five rights.
- monitor closely the
patient for any side
effect of the drugs
given.
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DOROTHEA E JOHNSON’S BEHAVIOURAL
MODEL
Johnson define a system as a whole that function as a whole by virtue of the
interdependence of its parts individual strive to maintain stability and balance in those parts
through adjustment and adaptation to the forces, the impinge of them. A behaviour system is
pattern, repetitive and purposeful.
Johnson’s key concepts describe the individual as a behavioural system composed of
seven sub systems.
1) Attachment- Affiliative: Sub system provides survival and security. Its
consequences are social inclusion, intimacy and the formation and maintenance of
a strong social bond.
2) The dependency sub system: problem helping behaviour that calls for a nurturing
response. Its consequences of approval, attention or recognition and physical
assistance.
3) The ingestive system: Sub system satisfies appetite. It is governed by social and
psychological consideration as well as biologic.
4) The eliminative: Sub system excretes body wastes.
5) The sexual subsystem functions dually for procreation and gratification.
6) The achievement: Sub system attempts to manipulate the environment. It controls
or masters an aspect of the self or environment to some standards or excellence.
7) The aggressive: Subsystem protects and preserves the self and society within the
limits imposed by society.
Each of the above subsystem has the same functional requirement, protection
nurturance and stimulation. The subsystem’ responses are developed through motivation,
experience and learning and are influenced by bio-psychosocial factors.
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Other concepts associated with Johnson’s model are equilibrium, a stabilised but more
or less transitory resting state in which the individual is in harmony with the self and the
environment tension. A state of being stretched or stained and stressors. Internal or external
stimuli that produced tension and result in a degree of instability.
Assessment of Mr.Ravi Chandran by using Johnson’s Behavioural System
Model:
Eight Sub-systems:
Achievement-
Mr. Sushanth is 34 years old has basic education upto 10th standard, has one daughter
and one son. He has not accomplished all his responsibility in his life with regard to the
family. He wanted to see his children going to school.
Affiliative-
Mr. Sushanth is head of the family and all things under his control. He is working as a
auto driver. He is loved and respect by his friends and family members.
Aggressive/Protective-
Mr. Sushanth is not productive himself and used to take alcohol 2-3 pegs per day and
smoke 2-3 cigarettes per day.
Dependency-
Mr.Sushanth lives with his family and he is the only source of income, earned 1000-
1500 per month and now he feels alone and thinks how he will manage their economic
condition.
Eliminative-
He has no complaints of elimination previously and now he says that he is having
constipation for the last 3-4 days after the operation.
Ingestive-
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Mr. Sushanth has no complaint regarding food, no nausea or vomiting after admission.
He weight is not appropriate with his age and height. He takes two meals per day and he
takes mixed diet.
Restorative-
Mr. Sushanth is admitted with complaints abdominal pain
Sexual-
Mr. Sushanth is having a good relationship with his wife
Environment Assessment:-
Familial-
Mr. Sushanth has one daughter and one son, he wanted to see his children going to
school and becoming an educated person. He is worrying about his children education. He is
worried more about how he take care of his family.
Socio-cultural-
Mr. Sushanth belongs to Hindu religion. He believes god and go to temple. He
maintains regular social relationship with his relatives, friends and neighbour.
Ecological-
Mr. Sushanth lives in his own hose which is kaccha with two small rooms including the
kitchen. Their surrounding environment is unhealthy.
Developmental-
Mr. Sushanth is 34 years old man. he has a good relationship with his family members.
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DOROTHY E. JOHNSON’S BEHAVIOURAL SYSTEM MODEL
Attachment- unable to meet his family &
friends because of hospitalisation
Dependency-dependency for self Achievement- proper
care activity & living education for
his children
Protective- smoking and
drinking alcohol.
Ingestive- decreased appetite due to
smoking and alcohol, constipation.
Mr. Sushanth
34 years, male
Intestinal Obstruction
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Nursing Diagnosis (problem identified)
1. Pain (acute) related to incisional site as evidenced by report of pain, facial grimace,
restlessness.
2. Body temperature: imbalanced related to infection as evidenced by raised in
temperature, increased pulse rate.
3. Anxiety related to surgery and fear of death as manifested by restlessness increased
awakeness, facial tension.
4. Nutrition imbalanced: less than body requirement related to loss of appetite as
evidenced by considerable weight loss and paleness of eye.
5. Constipation related to lack of food and fluid intake, immobility as manifested by
infrequent passage of stool.
6. Knowledge deficit regarding disease condition, treatment regimen and prognosis as
evidenced by lack of questioning and verbalized.
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Nursing theory Assessment Nursing
diagnosis
Goal Planning Implementation Evaluation
Johnson behavioural
system model:-
It is identified that due
to the mode of
intervention, the client
has pain in the
incisional site, nurses
identified the problem
and take appropriate
action or intervention.
Subjective data:
The client says, “I
am having pain in
the incisional
region.”
Objective data:
-facial grimace
-restlessness
-irritable
-pain scale measure
40-60%
Pain (acute)
related to
incisional site as
evidenced by
report of pain,
facial grimace,
restlessness.
Relieving of
pain
-assess the level of pain.
(severity & location)
-provide adequate and
comfortable position.
-check the incisional site
for redness or swelling.
-maintain pain scale for
the client.
-daily changing of
dressing under sterile
technique.
-instruct the client to
report pain.
-monitor other associated
signs and symptoms.
-administer medication
as prescribed.
-assessed the level of pain.
(severity & location)
-provided comfortable
position and adequate rest.
-incisional site checked for
redness and swelling.
-pain scale maintained.
-dressing changed under
sterile technique.
-instructed the client to
intimate if he feels pain.
-vital signs monitoring
done every 15 minutes.
-Inj. Tramadol 50 mg IV
given.
-20%.
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Nursing theory Assessment Nursing
diagnosis
Goal Planning Implementation Evaluation
Johnson behavioural
system model:-
Subjective data:
The client says, “I
will die today or
tomorrow and i
won’t be able to
recover from my
surgery.”
Objective data:
-facial tension
-poor eye contact
-increased
questioning
Anxiety related
to surgery and
fear of death as
manifested by
restlessness
increased
awakeness,
facial tension.
Reducing the
anxiety of the
client.
-assess the level and
cause of fear.
-check client’s very often
and assure the client that
close monitoring ensure
prompt treatment.
-encourage client to call
for nurse when pain or
fear develops.
-establish rest period
between care and
procedure.
-provide adequate rest
and a quiet and calm
environment.
-explain about the
disease condition and
prognosis and treatment
regimen.
-the client is having
moderate pain.
-every 15 minutes asked
the client about his
condition and vital signs
monitor.
-encourage him to respond
to his pain and fear by
calling the nurse.
-rest period is provided
between the procedure.
-quiet and calm
environment provided.
-explained to the client
about the disease
condition, treatment and
prognosis in simple and
understandable words.
The client
appears calm
and express trust
in medical
treatment.
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Nursing theory Assessment Nursing
diagnosis
Goal Planning Implementation Evaluation
Johnson behavioural
system model:-
It is identified that due
to mode of
intervention, nurses
identified problem of
imbalanced nutrition
and take appropriate
action or intervention.
Subjective data:
The client says, “I
am not having
appetite.”
Objective data:
-weight loss
-Ryle’s tube present.
-look anorexic
Nutrition
imbalanced: less
than body
requirement
related to loss of
appetite as
evidenced by
considerable
weight loss and
paleness of eye.
To maintain
normal body
weight of the
client.
-assess the weight of the
patient.
-monitor laboratory
values indicate
nutritional well-being.
-encourage calorie intake
appropriate for body
type and life-style.
-encourage client to be
more aware of
nutritional habits.
-discourage smoking and
alcohol and explain
about its hazards.
-advise and encourage
for oral care before and
after meals.
-aspiration to be done
-the client’s weight is 53
kg and is not appropriate
with the height.
-monitored laboratory
values of serum
Hb=11.2gm/dl.
-encouraged the client to
take high calorie high
protein diet like dal, egg,
milk, and green vegetables.
-explain the client the
hazards of smoking and
alcohol.
-advised for oral care
before and after each feeds.
-aspiration done before
every tube feeding.
The client is
able to take food
by mouth.
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Nursing theory Assessment Nursing
diagnosis
Goal Planning Implementation Evaluation
Johnson behavioural
system model:-
It is identified that due
to mode of
intervention, nurses
identified problem of
constipation and take
appropriate action or
intervention.
Subjective data:
The client says, “I
am not passing stool
regularly.”
Objective data:
-bowel sound
absent.
Constipation
related to lack of
food and fluid
intake,
immobility as
manifested by
infrequent
passage of stool.
To maintain
normal
elimination
pattern.
-assess the bowel sound,
movement, type of stool
pass.
-advise the patient to
take more vegetables,
which contain fiber and
fruits for easy digestion.
-advise to take more
fluids such as more
amount of water,
coconut water etc.
-encourage patient to
increase bowel
movement by his own.
-establish daily routines
-assessed the bowel sound,
movement, type of stool
pass.
-advised the patient to take
more vegetable items,
which contain fiber and
fruits for easy digestion.
-advised to take more
fluids such as more amount
of water, coconut water etc.
-encouraged patient to
increase bowel movement
by his own.
-established a daily
routines to have a regular
The client
identifies and
consumes foods
high in fibre.
before every feeding.
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to have a regular timing.
-maintain privacy and
position for defecation
timing
Nursing theory Assessment Nursing
diagnosis
Goal Planning Implementation Evaluation
Johnson behavioural
system model:-
It is identified that due
to mode of
intervention, nurse
identified problem of
fever, and take
appropriate action or
intervention.
Subjective data:
The client says, “I
am feeling very hot
and my body are
aching.”
Objective data:
-T= 101 0 F
P=96 bpm
Resp.= 22/ min
BP= 120/70mmHg
Body
temperature:
imbalanced
related to
infection as
evidenced by
raised in
temperature,
increased pulse
rate.
To maintain
the normal
body
temperature.
-assess the condition of
the client.
-monitor the vital signs
every 15 minutes.
-advise to drink more
fluid like fruit juices,
coconut water etc.
-advise to remove excess
clothing.
-encourage taking high
calorie high protein diet
like egg, milk, meat and
-assessed the condition of
the client.
-vital signs monitor every
15 minutes.
-advised to drink more
fluid like fruit juices,
coconut water etc.
- excess clothing removed
from the client’s bed.
-encouraged taking high
calorie high protein diet
like egg, milk, meat and
Temperature
reduced
T-99.80F
Pulse- 90bpm
Resp- 20/min
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green vegetables.
-encourage cold
compress.
-administered
medication if prescribed.
green vegetables.
-cold compress given.
Nursing theory Assessment Nursing
diagnosis
Goal Planning Implementation Evaluation
Johnson behavioural
system model:-
It is identified that due
to mode of
intervention, nurse
identified problem of
lack of knowledge and
take appropriate
action or intervention.
Subjective data:
The client says, ““I
am not able to
understanding my
condition.”
Objective data:
Asking too many
questioned regarding
his condition.
Knowledge
deficit regarding
disease
condition,
treatment
regimen and
prognosis as
evidenced by
lack of
questioning and
verbalized.
To increased
the
knowledge
level of
patient
-assess the level of
knowledge of the client
about the disease and
treatment.
-explain to the client in
simple and
understandable words
regarding the disease
condition and treatment.
-encourage the client to
-assessed the level of
knowledge of the client.
- explained to the client in
simple and understandable
words regarding the
disease condition and
treatment.
-encouraged the client to
clear his doubt.
The client is
following the
treatment
regimen without
any confusion.
A COMPLETE COACHING FOR THE PREPARATION OF STAFF NURSE/AIIMS/PGI/RPSC/ B.Sc NURSING. /M/Sc.NURSING BY SAHU SIR-8947879143
clear his doubt.
-encourage the client to
ask and clarify all his
doubts.
-explain to the client
about the diet,
medication and
exercises.
-encouraged the client to
ask and clarify all his
doubts.
-explained to the client
about the diet, medication
and exercises.
A COMPLETE COACHING FOR THE PREPARATION OF STAFF NURSE/AIIMS/PGI/RPSC/ B.Sc NURSING.
/M/Sc.NURSING BY SAHU SIR-8947879143
Conclusion.
Mr. Sushanth came to hospital with the chief complaints of constipation and edema and
intestinal pain and he was diagnosed as intestinal obstruction and he underwent laprotomy
surgery now he is recovering from his condition.
Bibliography.
Lewis SM,Heitkemper MM,Dirksen SR.medical surgical nursing,assessment and management of clinical problems.6th ed.missouri:mosby;2004.p.1078-81.
Suzane cs,Brenda gb,jonice lh, Textbook of Medical-Surgical Nursing.10th ed.wolters klwwer; 2004.p1054-56.
Silverstri LA..comprehensive review of nclex.rn.examination .3rd ed.pennylvania:saunders;2006.p.677-87
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