Shing Shing Ncp 52

8/4/2019 Shing Shing Ncp 52

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Date/Time Cues Needs NursingDiagnosis

Objective ofCare

NursingIntervention

Evaluation

April 25,2011

3-114:30pm

Subjective:Nagasakit ang

akong tahi labi napag molihok ko asverbalized by theclient

Objective:

3 dayspost op

Protectivebehaviour

Uncomfortable

Grimmaceface

Pain scaleof 7 out of10 (1-3 asmild, 4-7asmoderate,

8-10 assevere)

Presenceof wounddressing,dry andintact

CO

GNITIVE

PE

RCEPTUAL

P

ATTERN

Acute Painrelated to

Presence ofSurgicalIncisionsecondary toCesareanSection The clientisexperiencingpain due to

theepisiotomydone to herafter the CSoperation.

Within the 6hours span

of nursingcare andmanagement, the patientwill be ableto:

a. Relieve frompain

b. Verbalizecomfort

1. Note location ofsurgical procedure

as this caninfluence the amountof postoperative painexperienced

2. Assess clientspain using a scale of1-10 with 1 beingleast, 10 being most.Assessment

provides objectivemeasurement of theclients perception ofpain.

3. Observe client fornonverbal signs ofpain; grimacing,guarding, pallor,withdrawal.

Observation helpsidentify discomfortwhen the clientdoesnt ask for help.

GOAL MET@ 9:30PM

Patient wasable to:a. Reliev

edfrom

pain asverbali

zedDili

nmankayosakit

makaya lngsya

b. Be ina

comfor

tablesituatio

n asevidenced bysleeping and

movingwithout


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Body tempof 38.1 C

ElevatedWBCresult of26.79

4. Assess locationand character of paineach time the clientreports discomfort.

Assessmentprovides info aboutthe cause of pain.Unusual pain mayindicatecomplications.

5. Monitor vital signsand record. Pain may alter

patients condition.

6. Provide comfortmeasures such asback rubTo promote nonpharmacological painmanagement

7. Instruct

in/encourage use ofrelaxation techniquesuch as deepbreathing exercises.To distractattention and reducetension

assistance


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8. Encouragediversionalactivities(socialization of others)

These enable thepatient not toconcentrate on thepain that shesexperiencing.

9. Encourageverbalization aboutthe pain. So that relief

measure may beinstituted

10. Give analgesics(Ketorolac) asordered, evaluatingeffectiveness andobserving for anysigns and symptomsof untoward effects.

Pain medicationsare absorbed andmetabolizeddifferently bypatients.


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Date/Time Cues Needs NursingDiagnosis

Objective ofCare

Nursing Intervention Evaluation

April 26,2011

3-115:00pm

Subjective:Nagdako jud

akong tiil, asverbalized by thepatient

Objective:

Edema onboth feet

Elevatedsodiumlevel of 137

Urinespecificgravity of1.015

NU

TRITIONAL

METABOLIC

PATTERN

Excess fluid

volume r/t

increasesodium level

both water

and sodium

are gained in

about the

same

proportions as

normallyexists in

extracellular f

luid. The total

body

sodiumconten

t is increased,

which in

turncauses an

increase in

total bodywater.

Reference:

Sparks and

Taylors

Nursing

Diagnosis

Witihin 5 hours ofnursing care,

patient will beable to:a. Have good

skinintegrity

b. Remainthe weightas thesame

1. Monitor andrecord vital

signs at leastevery 4 hours.: Changesmay indicatefluid orelectrolyteimbalances.

2. Measure andrecord intake

and output.: Intakegreater thanoutput mayindicate fluidretention andpossibleoverload.

3. Weigh patient at

same time eachday.: To obtainconsistentreadings.

GOAL UNMET@9:45PM

Patient was ableto:

a. Have agood skinintegrity asevidencedby good

skin turgor

b. Remain herweight


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4. Administerdiuretics

: To promotefluid excretion.

5. Maintain patienton sodium restricted diet,as ordered.: To reduceexcess fluid andprevent

reaccumulation

6. Repositionpatient every 2hours, inspectskin for rednesswith each turn,and institutemeasures asneeded.: Prevent skinbreakdown.


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7. Encouragepatient to cough

and deepbreatheexercise: To preventpulmonarycomplications.

8. Educate patientregardingmaintenance of

daily weightrecord, dailymeasuring andrecording ofintake andoutput, diuretictherapy, anddietaryrestrictions,especiallysodium.:ThesemeasuresencouragePatient toparticipate morefully.


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Date/Time

Cues Needs

NursingDiagnosis

Objective ofCare


April 25,20113-11

4:30pm

Subjective:kapoyan komaglihok kay

musakit akongtahi. as

verbalized by theclient

Objectives:

Needs

assistance indoing activities

Cautious ininitiating position

changes

Limitedrange of motion.

A

C

T

I

V

I

T

Y

E

X

E

R

C

I

S

E

P

A

T

T

E

R

N

Activityintolerance related

toincisionaldiscomfort

Extremedfatigue or

otherphysical

symptomscaused by

simpleactivity

Reference

: Sparks

and

Taylors

NursingDiagnosis

Within the 6 hoursspan of nursingcare and

management, thepatient will:

a) Perform anduse energy-

conservation-techniques.

b) Participatewillingly in

necessary/desiredactivities.

1. Note client reportsof pain and difficultyaccomplishing tasks. Symptoms may beresult of/ or contribute

to intolerance ofactivity.

2. Evaluate clientsactual and perceivedlimitations/degree of

deficit in light of usualstatus.

Providescomparative baseline

and providesinformation about

needededucation/interventions regarding quality of

life.

3. Ascertain ability tostand and move about

and degree ofassistance

necessary/use ofequipment.

GOAL MET @ 8:30PM

Patient was able to:a) Used energy

conservationtechniques sevidenced byalternatingrest inperiods oftme.

b) Participatedwillingly in

necessary/desiredactivities.


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To determinecurrent status and

needs associated withparticipation inneeded/desired

activities.

4. Encourage client tomaintain positive

attitude; suggest useof relaxation

techniques, such as

visualization/guidedimagery, asappropriate

To enhance wellbeing

5.Instruct the patientto ambulate as

tolerated this promotes better

wound healing

6. Assist with activitiesand provide/monitor

clients use of assistivedevices or use ofassistance from

others. To protect client


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from injury

7. Promote comfort

measures and providefor relief of pain to enhance ability toparticipate in activities

8. Assist the patientwith self care activities

as needed. Let thepatient determine how

much assistance is

needed Allows the patient tohave some control andchoice in plan; helps

the patient to graduallydecrease the amountof activity intolerance.

9. Provide positiveatmosphere, while

acknowledgingdifficulty of the

situation for the client. helps to minimize

frustration, rechannelenergy.


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10. Have specific

times set for visiting offriends or relatives to conserve energy


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Date/Time

Cues Needs

NursingDiagnosis

Objective ofCare


April 28,20113-114pm

Subjective/Objective:

6days postCS

(+) wounddressing- dry and intact- no secretion- no swelling- no redness

Length ofincision: 4inches

Temp =38.3 C

HEALTH

PER

CEPTIONHEALTH

MANA

Risk forinfectionrelated tosurgicalincision

Accentuated risk ofinvasion ofa surgical

wound byapathogenicorganism(bacteria,virus,fungus,protozoa,orparasite)from eitherendogenous orenvironmentalsources

Within the span of6 hours of shift,patient will beable to remainfree of infection,as evidenced by:

a) normaltemperature

b) absence ofpurulentdrainagefromincisions

c) incision is freeof redness,

swelling

1. Encourage patientwith a total bed bathdaily reducesmicroorganism on theskin

2. Wash your handsthoroughly betweeneach treatment

Prevents crosscontamination ofmicroorganisms.

3. Teach the patientthe value of frequenthand washingPrevents crosscontamination andnosocomial infections.

4. Use universalprecautions and teachthe patient thepurpose andtechniques ofuniversal precautionssuch as hand washingtechnique.

GOAL MET @8:45PM

Client was able toremain free ofinfection, as

evidenced by:a) Temp =

36.3 C

b) absence ofpurulent fromincisions and

c) incision was freeof redness, swelling


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GEME

NT

PATTERN

Reference

: Sparks

and

Taylors

NursingDiagnosis

Protects the patientfrom infection

5. Maintain adequate

nutrition and fluid andelectrolyte balanceHelps preventdisability that wouldpredispose infection

6. Encourageambulation, deepbreathing, coughing,position change for mobilization ofrespiratory secretions

7. Teach the patientabout the infectiousprocess, route,pathogens,environmental andhost factors andaspects of prevention. Provides basicknowledge for selfhelp and selfprotection


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8. Teach client towash handsfrequently, especiallyafter toileting, beforemeal, and before andafter administeringself-care. Clients can spreadinfection from one partof the body to another,as well as pick upsurface pathogens,hand washing reducesthese risks.

9. Assess dressings orincisions, noting ifdressing clean, dryand intact, if incisionsexhibit redness,edema, ecchymosis,drainage andapproximation. Assessmentprovides informationabout developinginfection. Localinflammatory effectscause of redness and


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edema. This may befollowed by purulentdrainage and arounddehiscence.

10. Provide patientabdominal binder it is a supportdevice for a patientwith an open incision


15/20

Date/Time

Cues Needs

NursingDiagnosis

Objective ofCare


April 26,20113-11

5:00pm

Objectives: Expressed fear of

unspecifiednegative outcome;feelings ofhelplesness orincapacity

Presence ofsweating

SE

L

F

P

E

R

C

E

P

T

I

O

N

S

E

L

Anxiety r/tchange inhealthstatus

Vague,

uneasy

feeling of

discomfort

or dread

accompan

ied by

autonomic

response.

Reference

: Sparks

and

Taylors

NursingDiagnosis

Within 4 hours ofnursingintervention thepatient will be

able to:

a. Acknowledge feelingsand identify

healthyways to

deal withthem.

1. Facilitatedevelopment as atrusting relationshipwith patient and family Trust is necessarybefore patient andfamily can feel free theopen personal linesand communicationwith hospice team and

address sensitiveissues.

2. Be available toclient for listening andtalkingto assist client inidentifying feelingsand begin to deal withproblems.

3. Clarify meaning offeelings/actions byproviding feedbackand checking meaningwith the client. to assist the client toidentify feelings

GOAL MET @8:00PM

Patient was able to:

Patientacknowledgedfeelings and

identifies


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F

C

O

N

C

E

P

T

3. Provide open,

nonjudgmentalenvironment. Usetherapeuticcommunication skills. Promotes andencourage dialogueabout feelings andconcerns.

4. Encourage

verbalization ofthoughts and concernsand acceptexpressions ofsadness and anger. Patient may feelsupported expressionof feelings byunderstanding thatdeep and often

conflicting emotionsare normal in thissituation.

5. Provide accurateinformation about thesituationhelps the clientidentify what is reality


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based.

6. Reinforce teaching

regarding diseaseprocess andtreatments andprovide information asrequested. Be honest;do not give false hopewhile providingemotional support. Patients benefitfrom factual

information. Honestanswer promotestrust.

7. Assist the patient indeveloping anxiety-reducing skills Using anxiety-reduction strategiesenhances patients

sense of personalmastery andconfidence.


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8. Emphasize thelogical strategies

patient can use whenexperiencing anxiousfeelings. Learning to identifya problem andevaluate alternativesto resolve it helps thepatient to cope

9. Assist patient in

recognizing symptomsof increasing anxiety;explore alternatives touse to prevent theanxiety fromimmobilizing her orhim The ability torecognize anxietysymptoms at lower-

intensity levelsenables the patient tointervene more quicklyto manage his or heranxiety. Patient will beeffectively when thelevel of anxiety is low.


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10. Instruct patient inthe proper use ofmedications andeducate him torecognize adversereactions Medication may beused if patientsanxiety continues toescalate.


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Documents

Shing Shing Ncp 52