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Diagnosis
Goal of Care
Patient Will:
Intervention
1. Verbalization of 6/10
rate of pain to a score
of 4/10 and below.
2. Absence of facial
grimaces
Rationale
Evaluation
Assess non-verbal
cues for pain
3. With minimal
guarding of
the affected
area.
4. Expected
exacerbations,
reported their
quality &
avoid complication of
analgesic use (eg.
constipation).
Provide
nonpharmacological
comfort measures
(repositioning)diversi
onal activities
(television) deep
breathing exercises
18
intensity.
5. Demonstrated
use of
relaxation
skills and
diversionall
activity as
indicated for
individual
situation.
8. Followed
prescibed
regimen.
Inform patient/So of
the expected
therapeutic effects
and discuss
management of side
effects.
Administer
medication as
indicated, Tramadol
realistic expectations,
confidence in own ability to
handle what happens.
NCP 2: Nutrition: Imbalanced, Less than body requirements r/t decrease appetite secondary to disease process
19
Assessment
Pale conjunctiva and
mucous membranes.
Dry, wrinkled, sagging
of the skin
Diagnosis
Nutrition:
Imbalanced, Less
than body
requirements r/t
decrease appetite
secondary to
disease process
Goal of Care
Patient Will:
1. Drink 6-8 glasses a
day.
2. Responds positively to
his favorite foods if
there
is
no
contraindication.
3. Reports increase
appetite.
Rationale
Assess the
amount of food eaten
Monitor I and O
in
4. Manifests absence of
signs of malnutrition.
Provide frequent
small meals & a
comfortable &
pleasant
environment.Offer
small frequent sips of
water
5. Participate in specific
interventions
to
stimulate appetite.
20
Intervention
Provide oral
hygiene
Provide rest
periods after meals
Create pleasant
dining atmosphere;
Evaluation
Goal is met if patient:
1.
Drinks
6-8
glasses a day.
2.
Responds
positively
to
his
favorite foods if there
is no contraindication.
3.
Reports
increase in appetite.
4.
Manifests
absence of signs of
malnutrition.
5.
Participate in
specific interventions
to stimulate appetite.
encouraged patient to
eat with family
members/friends
Encouraged open
communication
regarding decrease
appetite or intake of
food
Assessment
Patient has Prostate Ca,
Stage IV
-with foley catheter
-with IVF
Diagnosis
Risk for Infection r/t
Immunosuppression
secondary to disease
process
Goal of Care
Intervention
Promote good
hand washing procedures
by staff and visitors.
Emphasize
personal hygiene.
22
Rationale
Vital signs are good indicators of
a possible infection. An
increased in vital signs indicates
bodys compensatory mechanism
against bacterial invasion. Early
indication of infectious process
enables appropriate therapy to be
started promptly
Early indication of infectious
process enables appropriate
therapy to be started promptly.
Early recognition and
intervention may prevent
progression to more serious
situation or sepsis.
Protects patient from sources of
infection.
Limit potential sources of
infection and secondary
overgrow.
Evaluation
Goal is met if :
1.
Patient
maintained vital
signs within normal
limits.
2.
Patient and
significant others
identified and
participated in
interventions to
prevent/reduce risk
of nosocomial
infection
Administer
antibiotic as indicated
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