Super Final Ncp

XIV. NURSING CARE PLAN

CuesNursing

DiagnosisInference Planning Intervention Rationale Evaluation

Subjective:“Sumasakit yung kaliwang suso ko”

Objective:

> 5/10 Pain Scale> (+) Facial Grimace> (+) Guarding Behavior> (+) restlessness> Post Modified Radical Mastectomy

Acute Pain Related to

Post- Surgical Tissue

Damage

Post Modified Radical

Mastectomy

Actual Tissue Damage

Unpleasant Sensory / Emotional Experience

Acute pain

SHORT TERM:After 8 hours of nursing intervention, the patient will rate the Pain scale from 5 to 2.

LONGTERM:After several weeks of nursing intervention, the patient will able to demonstrate nonphramacological methods that can relief pain.

INDEPENDENT:

1.) Observe nonverbal cues and pain behavior

2.) Monitor skin color, temperature, vital signs.

DEPENDENT:1.) Note Client’s attitude towards pain and use of pain meications.

2.) Administer Analgesics as indicated

> Observation may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize

> Altered Vital signs may be an indicator of acute pain.

> To maintain acceptable level of pain.

> To maintain acceptable level of pain.

SHORT TERM:After 8 hours of nursing intervention, the patient was able to rate the Pain scale from 5 to 2.

LONGTERM:After several weeks of nursing intervention, the patient was able to demonstrate nonphramacological methods that can relief pain.

COLLABORATIVE:

1.) Discuss with SO the ways in which they can assist the client and reduce precipitating factors that may cause / increase pain (household task)

> To minimize pain and reduce precipitating Factors

CuesNursing


Subjective:“pangit ko na ba?”Objective:

> Post operative Modified Radical Mastectomy

> (+) Guarding Behavior

> Not looking or not touching body parts

Disturbed Body Image

related to Post-surgical Modified Radical

mastectomy

Post Surgical Modified Radical

Mastectomy

Missing body parts

Altered body structure / function

Dissatisfaction in physical appearance

Distured Body Image

SHORT TERM:After 8 hours of nursing intervention, the patient will verbalize understanding of body changes and verbalize acceptance of self situation.

LONGTERM:After several weeks of nursing intervention, the patient will able to use adaptive devices and actively pursue growth

INDEPENDENT:

1.) Evaluate level of client’s knowledge, anxiety related to situation and observe emotional state.2.) Plan care activities with client.

3.) Maintain positive approach during care activities, avoiding expressions of disdain or revulsion. Do not take angry expressions of client/SO personally.

DEPENDENT:

> Indicates acceptance/ non-acceptance to the situation.

> Promotes sense of control and gives message that client can handle situation, enhancing self-concept.> Assists client/SO to accept body changes and feel good about self. Anger is most often directed at the situation and lack of control or powerlessness individual has over what has happened—not with the individual caregiver.

SHORT TERM:After 8 hours of nursing intervention, the patient was able to verbalize understanding of body changes and was able to verbalize acceptance of self situation.

LONGTERM:After several weeks of nursing intervention, the patient was able to use adaptive devices and actively pursue growth

1.) Note signs of grieving / indicators of severe or prolonged depression.

2.) Discuss the availability of physical therapy / reconstructive.

COLLABORATIVE:

1.) Begin counseling / other therapies

2.) Refer to Appropriate support group

> To evaluate need for counseling/ medications

> To minimize surgery and body changes and enhance appearance

> To provide early / ongoing sources of support.

> to promote optimal wellness.

CuesNursing


Subjective:

Objective:

> Post Modified Radical mastectomy> (+)Destruction of Skin Layers

Impaired Skin Integrity

Related to Post Modified Radical

Mastectomy

Post Modified radical

Mastectomy

Altered Epidermis/

Dermis

Impaired Skin Integrity

SHORT TERM:After 8 hours of nursing intervention, the patient will able to display timely healing of skin lesions, wounds or pressure without complications.

LONGTERM:After several weeks of nursing intervention, the patient will able to verbalize feelings of self-esteem and ability to manage situation.

INDEPENDENT:

1.) Identify underlying condition or pathology

2.) Inspect surrounding skin for erythema, induration, maceration.

DEPENDENT:

1.) Obtain pyschological assessment of client’s emotional status, as indicated.

COLLABORATIVE:

1.) Consult with wound or stoma specialist

> To identify causative / contributing factors.

>To assess extent of involvement and injury

> To determine impact of condition

> To assist with developing plan of care for problematic or potentially serious wounds

SHORT TERM:After 8 hours of nursing intervention, the patient was able to display timely healing of skin lesions, wounds or pressure withoout complications.

LONGTERM:After several weeks of nursing intervention, the patient was able to verbalize feelings of self-esteem and ability to manage situation.

CuesNursing


Subjective:

Objective:

> Inappropriate / exaggerated behavior.

> Statements of misconceptions.

Deficient Knowledge Related to

Lack of Information

Lack of Specific Information

Misinterpretations/Inacurate/ Incomplete Information

Cognitive Limitations

Deficient Knowledge

SHORT TERM:After 8 hours of nursing intervention, the patient will able to verbalize understanding of condition and prticipate in learning process

LONGTERM:After several weeks of nursing intervention, the patient will able perform necessary procedures correctly and initiate necessary lifestyle changes and participate in treatment

INDEPENDENT:

1.) Determine Client’s ability, readiness and barriers to learning.

2.) Provide Information relevant only to situation.

3.) Begin with the informations that the client already knows and move to complex. Use short and simple sentances

COLLABORATIVE:

1.) Provide Access information for contact person

2.) Identify available

> Patient may not be physically, emotionally or mentally capable at this time.

> To prevent overload

> Can elevate client’s interest.

> To answer questions and

SHORT TERM:After 8 hours of nursing intervention, the patient was able to verbalize understanding of condition and participate in learning process

LONGTERM:After several weeks of nursing intervention, the patient was able perform necessary proocedures correctly and initiate necessary lifestyle changes and participate in treatment

regimen. community resources and support groups

validate informations.

> To promote wellness and discharge considerations

regimen.

CuesNursing


Subjective:

Objective:

> (+)slowed Movement.> (+) postural instability.> (+) limited range of motion.> (+) difficulty turning.> Post Modified Radical Mastectomy

Impaired Physical Mobility

Related to Prescribed Movement

Restrictions.

Prescribed Movement Restrictions

Inability to perform gross or fine motor

skills

Impaired Physical Mobility

SHORT TERM:After 8 hours of nursing intervention, the patient will able to verbalize understanding of situation and individual treatment regimen and safety measures.

LONGTERM:After several weeks of nursing intervention, the patient will able to demonstrate techniques that enable resumption of activities.

INDEPENDENT:

1.) Note situations such as surgery that may restrict movement.

2.) Observe movement when client is unaware of observation

3.) Assist client to reposition self on a regular schedule

4.) Support affected body parts or joints using pillow

DEPENDENT:

1.) Administer medications prior to activity as needed for pain relief.

COLLABORATIVE:

1) Consult with

> To identify contributing factors.

> To note any incongruencies with reports of abilities

> To promote optimal level of function and prevent complications.

> To prevent risk of pressure ulcer.

> To permit maximal effort and involvement in activity.

SHORT TERM:After 8 hours of nursing intervention, the patient was able to verbalize understanding of situation and individual treatment regimen and safety measures.

LONGTERM:After several weeks of nursing intervention, the patient was able to demonstrate techniques that enable resumption of activities.

physical or occupational therapist, as indicated. > To develop

individual exercise and mobility program, and identify appropriate mobility devices.

CuesNursing


Subjective:

Objective:

> indesive or nonassertive behavior.

Risk for sitational Low

Self-Esteem Related to

Loss of Body Parts


mastectomy

Loss of Body Parts


Distured Body Image

Risk for sitational Low Self-Esteem

SHORT TERM:After 8 hours of nursing intervention, the patient will able to acknowledge factors that lead to possibility of Low-Self-Esteem feelings.

LONGTERM:After several weeks of nursing intervention, the patient will able to demonstrate self-confidence by actively participating in life situation.

INDEPENDENT:

1.) Note for non-verbal body language

2.) Assess negative attitudes and/or self-talk.

3.) Identify client’s basic sense of self-worth.

4.) Encourage expressions of feelings and anxiety.

5.) Active listen to client’s concerns and negative verbalizations without comment/ judgement

6.) Convey confidence in client’s ability to cope with current

> To determine incongruencies between verbal and non-verbal communication require clarification.

> To detect view of situation as hopeless and difficult.

> To assess contributing factors.

> facilitates greiving the loss body parts.

> To assist client to deal with the loss or changes.

SHORT TERM:After 8 hours of nursing intervention, the patient was able to acknowledge factors that lead to possibility of Low-Self-Esteem feelings.

LONGTERM:After several weeks of nursing intervention, the patient was able to demonstrate self-confidence by actively participating in life situation.

situation

COLLABORATIVE:

1) Promote attendance in therapy / support group.

> To recapture sense of positive self-esteem.

> To promote wellness.

CuesNursing


Subjective:

Objective:

>(+) powerlessness> (+) broken skin> Post Modified Radical Mastectomy.

Risk for Infection

Related to Broken tissue.


mastectomy

Traumatized tissue and

broken skin

Inadequate Primary defense

Increase Risk of Pathogenic Organism Invasion

Risk for Infection

SHORT TERM:After 8 hours of nursing intervention, the patient will able to identify interventions to prevent and reduce Risk of Infection.

LONGTERM:After several weeks of nursing intervention, the patient will able to achieve timely wound healing ; be free of Purulent Drainage, Erythema and be febrile.

INDEPENDENT:

1.) Note risk factors for occurence of infection (skin/tissue wounds/invasive procedures)

2.) Assess and document skin conditions around insertion of drainage

3.) Note signs and symptoms of sepsis (systemic infection) : fever, chills, altered LOC.

4.) Stress proper hand hygiene by all caregivers between therapies and clients

5.) Maintain Sterile Technique for all invasive procedures

DEPENDENT:1.) Administer

> To assess contributing / causative factors.



> A first line defense against healthcare assosiated infections.

SHORT TERM:After 8 hours of nursing intervention, the patient was able to identify interventions to prevent and reduce Risk of Infection.

LONGTERM:After several weeks of nursing intervention, the patient was able to achieve timely wound healing ; be free of Purulent Drainage, Erythema and be febrile.

medication regimen as ordered

COLLABORATIVE:

1) Obtain appropriate tissue/ fluid specimens for observationand cultural sensitivities testing.

> To reduce/correct existing risk factors.

> To determine effectiveness of therapy.


CuesNursing


Subjective:

Objective:

>(+) disbelief feeling> (+) helplessness> (+) Pain

Risk for Complicated

Grieving Related to Loss of Significant

Body Part.


mastectomy

Loss of Significant Body

Part

Altered body structure / function


Distured Body Image

Low-Self Esteem

SHORT TERM:After 8 hours of nursing intervention, the patient will able to discuss meaning of loss.

LONGTERM:After several weeks of nursing intervention, the patient will able to verbalize sense of beginning to deal with grief process.

INDEPENDENT:

1.) Determine Loss that has occured and meaning to the client. Note whether loss was sudden or expected.

2.) Discuss meaning of loss to client, Active-Listening response to client without judgement.

3.) Respect client’s desire for quiet, privacy, talking or silence.

4.) Meet with both members of couple.

COLLABORATIVE:

1) Refer to other resources, such as

> To identify contributing / causative factors

> To assist client to deal with the situation.


> To determine how they are dealing with current situation.

SHORT TERM:After 8 hours of nursing intervention, the patient will able to discuss meaning of loss.

LONGTERM:After several weeks of nursing intervention, the patient will able to verbalize sense of beginning to deal with grief process.

Risk for Complicated

Grieving

counseling , psychotherapy, spiritual advisor, cancer survivor groups.


Documents

Super Final Ncp