CARE OF CLIENTS ACROSS THE LIFESPAN WITH PROBLEMS ININFLAMMATORY AND IMMUNOLOGIC REACTIONS, CELLULARABERRATIONS, ACUTE BIOLOGIC CRISIS, INCLUDING EMERGENCYAND DISASTER NURSING
ncpFull description
Full description
Full description
Nursing Care PlanFull description
X.
NURS NURSIN ING G CARE CARE PLAN PLANS S
ASSESSMENT
DIAGNOSIS
PLANNING
NURSING INTERVENTIONS INT ER ERV EN ENT IO ION S
SUBJECTIVE:
“Masakit ang tahi ko” as verbalized by the patient. OBJECTIVE:
Restlessness Irritability With cold clammy skin Excessive perspiration Facial grimace Increased respiration RR=26 bpm Pain scale = 7: pain scaling of 110 where 1 is the least painful and 10 is the most painful Impaired thought
Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.
After 4 hours of nursing intervention patient’s pain evidenced by pain scale =7 be reduced to 3.
Change the position of the patient Provide comfort measures Assist patient in breathing techniques
R AT ATI O ON N AL AL E
Provide quiet environment
Relay on the patient report of pain Encoura ge divertional activities Monitor vital sign Administer analgesic as ordered by the AP
EVALUATION
Pain is sometimes due to the position of the patient To reduce the discomfort To assist in muscle and generalized relaxation For patient comfortabili-ty comfortabili-ty and lessen the discomfort. To reduce anxiety felt by the patient To divert the attention from pain to activities Usually altered in pain. To maintain acceptable level of pain.
After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.
ASSESSMENT
DIAGNOSIS
PLANNING
NURSING INTERVENTIONS INT ER ERV EN ENT IO ION S
OBJECTIVE:
Poor skin turgor Dry lips Weak in appearance Pale looking v/s of: BP = 100/80 PR = 64 RR = 26 T = 37.8
Fluid volume deficit related to the risk of post-operative hemorrhage as manifested by poor skin turgor, dry lips.
After 8 hours of nursing intervention the patient will maintain fluid at a functional level.
Change dressings frequently
Provide frequent oral care
To protect the skin and monitor losses
To prevent injury from dryness
Helps maintaining fluid in the body
To monitor fluids in the body
To assess the patient and it serve as base line data To reduce blood loss
Measure input and output
Monitor v/s
Administer IV fluids as indicated Give medications as ordered by the attending physician
EVALUATION
R AT ATI O ON N AL AL E
After 8 hours of nursing intervention, the patient was maintained fluid as manifested by good skin turgor
ASSESSMENT
DIAGNOSIS
PLANNING
NURSING INTERVENTIONS IN TE TE RV RVE NT NT IO IONS
EVALUATION
RA TI TI O ON NA LE LE
SUBJECTIVE:
“Hindi ako makagalaw ng ayos” as verbalized by the patient. OBJECTIVE:
Impaired ability to turn side to side. Cannot eat without support Slowed movement Irritable Limited ROM
Impaired mobility related to decreased muscle strength as manifested by limited ROM.
After 8 hours of nursing intervention the patient will be able move safety and independently .
Provide activities with adequate rest period.
To reduce the fatigue
Encouraged adequate intake of fluids
Advise to move hands and legs slowly
To exercise/mobiliza tion of body parts and develop muscle strength
Enhances self concept and sense of independence
Encourage participation in self care
Promotes well being and maximize energy production
After 8 hours of nursing intervention, the patient was able to move safely and independently .
