1.

ACUTE PAIN R/T TISSUE TRAUMA SECONDARY TO WOUND DEBRIDMENT SUBJECTIVE AND OBJECTIVE CUES S> Ang sakit ng tiyan ko! O> facial grimacing noted Aldrete score of 10 s/p wound exploration With dry and intact dressing Abdominal guarding noted Moaning noted Restlessness noted Vital signs of bp = 130/90mmhg; PR = 89bpm; RR = 23cpm; T = 35.8C Oriented to time, place, person and situation Medications taken were Ketorolac IV and Morphine sulphate 30ml for 10 mins EXPLANATION OF PROBLEM Last year the patient was confined due to rectal cancer and has undergone exploratory laparotomy for 2 times. Last week the patient had wound dehiscence so had undergone emergency wound exploration for debridement and suturing. After the procedure, the patient stayed in the RR and complained of pain in the abdominal area. OBJECTIVES STO: Within 8 hours of dependent and independent nursing interventions, the patient will: a. Verbalize pain is relieved with a pain scale of 0-4/10 b. Be able to sleep continuously for a minimum of 3 hours c. Demonstrate proper use of pain management techniques such as DBE and splinting LTO: After 72 hours of nursing intervention the patient will a. Verbalize pain is relived with a pain scale of 0/10 b. Demonstrate proper use of pain management techniques such as DBE and splinting c. Show no signs of infection such as abnormal drainage from wound, fever, redness NURSING INTERVENTIONS Independent 1. Monitor vital signs 2. Assess level of consciousness 3. Assess PQRST of pain RATIONALE Vital signs are usually altered in acute pain Pain can result in narrowed focus preventing the patient to assess the current situation Pain is a subjective experience and must be described by the client in order to plan effective treatment Indicate if there is an on-going infectious process Observations may or may not be congruent with verbal reports indicating need for further evaluation Noise may be a factor which can aggravated feeling of pain therefore should be minimized or eliminated DBE helps the body relax and contributes to pain relief by reducing muscle tension and anxiety To promote circulation and prevent tissue pressure To prevent fatigue EVALUATION STO: Objective partially met since the patient was able to sleep for 1 hour following pharmacologic treatment for pain Modification: Reassess PQRST of pain and Reinforce pain management techniques

4. Assess wound dressing and wound site 5. Observe for nonverbal cues of pain 6. Provide minimally stimulating environment 7. Encourage and assist client in deep breathing exercises 8. Encourage patient to turn gradually 9. Encourage adequate rest periods Dependent 1. Administer pain medications as ordered 2. Assist with laboratory or diagnostic procedures 3. Evaluate, with the patient and the health care team, the effectiveness of past pain control measures that have been used

Nursing Diagnosis: Acute pain related to tissue trauma

For faster relief of intolerable pain To identify underlying cause of pain

To make adjustments if necessary regarding the dosage and treatment of the patient

2. DECREASED CARDIAC OUTPUT R/T PLAQUE OCCLUSION SUBJECTIVE AND OBJECTIVE CUES O> Decreased Erythrocyte .33 (.37-.47); Decreased Hemoglobin 110 (120-170) as of 1/10/12 Electrolytes within normal range Oriented to time, place, person and situation With pale and cool skin With coughing episodes With vital signs of bp = 130/90mmhg; PR = 89bpm; RR = 23cpm; T = 35.8C With irregular pulse rhythm With cordarone drip x 24 hours Hooked to a cardiac monitor showing atrial fibrillation s/p wound debridement Restlessness noted With IFC and suprapubic catheter With 02sat of 70-80% at room air 90-100% with o2 therapy Nursing diagnosis: Decreased Cardiac Output R/T Plaque Occlusion EXPLANATION OF PROBLEM Due to the formation of fatty deposits in the walls of the blood vessels, the blood vessels narrowed decreasing blood flow. This decrease in blood flow creates high pressure causing the hypertension of the patient. Accompanied by decreased cardiac volume there is also decreased perfusion to myocardial muscles impairing the pumping ability of the heart hence produces signs and symptoms of dysrhythmia OBJECTIVES STO: Within 8 hours of nursing intervention the patient will display: a. BP= 120/80 mmhg b. PR = 60- 100 bpm regular rhythm c. Urinary output >30cc per hour d. RR=16-20 cpm regular e. Normal sinus rhythm f. O2sat of 90-100% LTO: After 72 hours of nursing intervention the patient will demonstrate: a. Increase in activity tolerance b. Stable vital signs as mentioned above c. No episodes of dysrhythmias d. Participate in activities that reduce workload of heart NURSING INTERVENTIONS Independent 1. Monitor vital signs 2. Review laboratory results and ECG results 3. Assess level of consciousness 4. Auscultate lung and heart sounds 5. Observe for chest pain or discomfort RATIONALE Indicate effectiveness of treatment and other underlying symptoms To note for any changes and make appropriate adjustments to treatment To note for possible oxygen insuffiency The new onset of a gallop rhythm, tachycardia, and fine crackles in lung bases can indicate onset of heart failure. Chest pain/discomfort is generally indicative of an inadequate blood supply to the heart, which can compromise cardiac output Monitor cardiac status and be prepared for other complications Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output. Elevating the head of the bed may decrease the work of breathing, and also decrease venous return and preload. Straining when defecating that results in the Valsalva maneuver can lead to dysrhythmia, decreased cardiac function, and sometimes death. Rest periods decrease oxygen consumption. EVALUATION STO: Objective partially met since patient was not able to ahieve a normal sinus rhythm within the shift and RR is 23cpm; PR is of irregular rhythm Modification: Continue interventions and monitoring

6. Maintain on cardiac monitoring 7. Monitor intake and output 8. Place client in semiFowler's position or position of comfort 9. Instruct patient not to do valsalva maneuver

10. Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. 11. Weigh client at same time daily.

An accurate daily weight is a good indicator of fluid balance.

Dependent 1. Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician's order. 2. Administer oxygen as needed per physician's order. 3. Gradually increase activity Serve small sodium1. restricted, lowcholesterol meals. 2. Administer blood or fluid replacement as ordered To ensure maintenance of a delicate balance of medications that stimulate the heart to increase contractility, maintaining adequate perfusion of the body.

Increase circulating oxygen in the body

Activity of the cardiac client should be closely monitored and should be gradual as not to overwork the heart Sodium-restricted diets help decrease fluid volume excess. Low-cholesterol diets help decrease atherosclerosis. Replace lost fluids and maintain cardiac output to normal