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NCP post varicocoelectomy

NCP post varicocoelectomy

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Published by Iris Caberte

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Categories:Types, Research, Science
Published by: Iris Caberte on Aug 19, 2010
Copyright:Attribution Non-commercial

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05/12/2014

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LIST OF PRIORITY PROBLEM

The first will be Acute pain r/t presence of surgical incision because it falls under physiological need of Maslow¶s hierarchy of needs. Second will be Sexual dysfunction r/t altered body structure as manifested by the presence of surgical incision which falls under love and belonging of Maslow¶s hierarchy of needs. Lastly is Risk for infection related to post operative site because it falls under physiological need of Maslow¶s hierarchy of needs.

Assessment
Nursing
Diagnosis
Rationale
Goals and
Objectives
Implementation
Rationale
Evaluation
Subjective:
³Kumikirot yung
bandang
inoperahan´

as verbalized by the client.

Objective:
Pain scale of
5/10
O b ser ve d
facial grimace
Guarding
behavior of the
incision site
Positioning to
avoid pain
Acute
pain r/t
presence
of
surgical incision
Post-surgical pain is a

complex response to tissue trauma during surgery that stimulates hypersensitivity of the central nervous system.

After 4 hours of nursing intervention, the client will be able to verbalized relief of pain and feel relaxed or at least the pain is reduced from pain scale of 5/10 to 3/10.

Keep at rest in semi-fowlers
position.
Place cold compress on the
incision site

periodically during initial 24-48 hours as appropriate.

Instruct in use of relaxation
techniques such as focused
breathing,
imaging,
and
music.
Administer analgesics, as
indicated.
Evaluate
and
document
client¶s response to analgesia.
Gravity

localizes inflammatory exudates into pelvis, relieving abdominal

tension, which is accentuated by supine position.

Soothes and relieves
pain
through
desensitization
of
nerve endings.
To distract attention
and reduce tension.
Relief pain facilitates
cooperation with other
therapeutic regimen.
O ng oi n g

evaluation will assist in making necessary adjustments for

effective
pain
management.

After 4 hours of nursing intervention, the client was able to verbalize

pain
is
reduced from pain
scale of 5/10 to 3/10.
Assessment
Nursing
Diagnosis
Rationale
Goals and
Objectives
Implementation
Rationale
Evaluation
Subjective:

³Sabi ng doctor bawal daw ako makipag-sex for 1 week´

as verbalized by the client.

Objective:
Inguinal
incision site
The client is
sad

Sexual dysfunction r/t altered body structure

as manifested by the presence

of
surgical incision
An

individual experiences a change in sexual function due to perceived

limitation
imposed by the surgery.

After 8 hours of nursing intervention, the client will able to discuss concerns about body image, sex

role,

and desirability as a sexual partner with significant other.

Determine importance of sex
to individual and client¶s
motivation of change.
Be alert to comments of client
Establish therapeutic nurse-
client relationship.
Provide factual information
about individual condition.
Provide privacy.
Interpersonal
problems, lack of trust
and
open
communication

between partners can contribute to client¶s concern.

Sexual concerns are

often disguised as humor, sarcasm, and offhand remarks.

To facilitate sharing of
sensitive information.
Provides
informed
decision making.
To
allow
sexual
expression

for
individual/partners
without
embarrassment/objecti
on of other.

After 8 hours of nursing intervention, the client was able to discuss concerns about body image, sex role, and desirability as a sexual partner with significant other.

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