Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
., as verbalized trauma secondary to by the client surgical incision as evidenced by (+) Objective: incison at lower quadrant V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg S/P TABHSO (+) incison at lower quadrant
CUES
GOAL
STG: After 3 days of proper nursing intervention, Independent: the patient display Inspect the wound timely healing of daily, or as wound without appropriate, for complications. changes.
RATIONALE
Promotes timely
Keep the area clean and dry and stimulate circulation to surrounding areas, by encouraging early ambulation.
Provide optimum
To provide a positive
nitrogen balance to aid in skin/tissue healing and to maintain general good health.
Provide changing of
wound dressing, as ordered by the physician and use an appropriate protective and healing devices (padding/cushion).
Collaborative: Obtain specimen from draining wounds when appropriate for culture/sensitivity
CUES
NURSING INTERVENTION
GOAL
NURSING INTERVENTION
RATIONALE
EVALUATION
Subjective: Masakit talaga yung tahi ko, as verbalized by the patient. - 1 is the lowest and 10 is the highest pain scale; Pain scale is 5/10 - dull pain -intermittent q2 Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg Guarding behavior, protecting body part (+)Facial grimace
Acute pain r/t tissue trauma secondary to surgical incision as evidenced by nonverbal cues such as (+) guarding and facial grimace
STG: Establish rapport After 1 hour of proper nursing intervention Independent: the patient reports Perform a that the pain is comprehensive relieved/ controlled. assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. Note changes.
STG: Goal Met. To rule out worsening of underlying condition/developmen t of complications. And in order to plan effective treatment.
Pain is a subjective Use pain experience and rating scale cannot be felt by appropriately (0-10 others. scale) and accept clients description of pain. Usually altered in acute pain.
To promote
Provide comfort
measure and encourage use of relaxation techniques such as touch, repositioning, nurses presence and deep breathing. Encourage verbalization of feelings about the pain.
To maintain
CUES
NURSING DIAGNOSIS
GOAL
NURSING INTERVENTION
RATIONALE
EVALUATION
Subjective: Panay kasi ang ubo ko kaya medyo hirap ako minsan sa paghinga, as verbalized by the patient. Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg
Ineffective Airway
STG: Establish rapport After 3 days of proper nursing intervention, Independent: the patient's Assess changes in Tachycardia and secretions are vital signs and hypertension may be mobilized and airway temperature. related to increased is maintained free of work of breathing. secretions, as Fever may develop in evidenced by clear response to retained lung sounds and secretions/atelectasis ability to effectively . cough up secretions Monitor respirations Indicative of after treatments and respiratory distress and breathe sounds, deep breaths. and/or accumulation noting rate and of secretions. sounds. Note changes. Elevate head of bed or change positions every 2 hrs. or prn. To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage to different lung segment. Hydration can help liquefy viscous secretions and improve secretion clearance. Relaxes the main air passages bronchi and eases breathing Various therapies maybe require maintaining adequate airway, improving respiratory function and gas exchange.
(+) crackles
Cough
Give expectorant or
bronchodilators as ordered.
CUES
NURSING DIAGNOSIS
GOAL
NURSING INTERVENTION
RATIONALE
EVALUATION
Subjective: Madalas akong magising dahil sa ubo, tapos isang oras bago ulit ako makatulog. as verbalized by the patient. Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg Restlessness
Disturbed Sleep STG: Establish rapport Pattern r/t frequent After 3 days of proper coughing as evidenced nursing intervention, Independent: by restlessness the patient achieves High percentage of Assessed sleep optimal amounts of sleep disturbances pattern disturbances sleep as evidenced by are affected by that are associated rested appearance, illnesses. with specific verbalization of feeling underlying illnesses. rested, and decrease in coughing. To facilitate Treat underlying treatment and cause.(cough) knowing the specific etiological factor will guide appropriate therapy. To determine usual Observed and sleep pattern and obtained feedback provide appropriate from clients intervention. regarding usual bedtime, routines, # of hours of sleep, and environmental needs. Did as much care as To avoid disturbances during sleep, and to possible without maximize sleeping waking the client, process. and did as much care as possible while the patient is still awake. So that patient will have an Explained necessity understanding of the of disturbances for importance of care monitoring VS and being done to him. care when Minimizes complaints hospitalized. Provide comfort measures (back rub). This soothes and relaxes the client.
Because of their
CUES
NURSING DIAGNOSIS
GOAL
NURSING INTERVENTION
RATIONALE
EVALUATION
Subjective: Nawawalan ako ng ganang kumain simula ng naospital ako, as verbalized by the patient. Diet Recall: Breakfast- Ensure (1 glass) Lunch- 4 tbs. of aroscaldo Dinner- 4 tbs. of aroscaldo Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg Wt: 37 kg Ht: 53 Decreased albumin (+) anemia (+) fatigue BMI: 14.45
Imbalanced Nutrition: Less than Body Requirements r/t disease process as evidenced by dietary intake
STG: After 1 week of nursing intervention, the patient will practice changes in her dietary intake by verbalizing selection of food and increase amount of food intakes including more nutritious foods in the diet.
Establish rapport Independent: Monitor weight regularly To establish baseline parameters and to monitor effectiveness of efforts Helps determine nutritional needs
To enhance intake Encourage client to and stimulate choose foods that appetite seems appealing and promote pleasant, relaxing environment Promote adequate/ timely fluid intake. Limits fluid 1 hour prior to meal Dependent: Administer pharmaceutical agents (Multivitamins) Collaborative: Consult dietician / nutritional team as indicated To reduce possibility of early satiety.
To implement interdisciplinary team management Source: Source: Nurses Pocket Guide,11th ed. by M. Doenges et al. p. 478-483
NURSING GOAL NURSING DIAGNOSIS INTERVENTION Subjective: Constipation r/t STG: Establish rapport changes in dietary After 2 days of proper Halos di ako intake as evidenced by nursing intervention Independent: makadumi kung hypoactive bowel the patient passes Assess usual di ako bibigyan ng soft, formed stool at a pattern of suppositories, as sound frequency perceived elimination; verbalized by the as "normal" by the compare with patient. patient. present pattern. Diet Recall: Include size, Breakfast- Ensure (1 frequency, color, glass) and quality. Lunch- 4 tbs. of aroscaldo Dinner- 4 tbs. of Evaluate laxative aroscaldo use, type, and frequency. Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 Encourage daily mmHg fluid intake of 2000 to 3000 ml/day, if Hypoactive bowel not contraindicated sound medically.
CUES
RATIONALE
"Normal" frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is "normal" for each individual. Chronic use of laxatives causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. Patients, especially elderly patients, may have cardiovascular limitations, which require that less fluid is taken. Fiber passes through the intestine essentially unchanged. When it reaches the colon, it absorbs water and forms a gel, which adds bulk to the stool and makes defecation easier
Encourage increased fiber in diet (e.g., raw fruits, fresh vegetables); a minimum of 20 g of dietary fiber per day is recommended.
Encourage physical
Ambulation and/or abdominal exercises activity and regular strengthen exercise. abdominal muscles Ambulation and/or that facilitate abdominal exercises defecation. strengthen abdominal muscles