Welcome to Scribd. Sign in or start your free trial to enjoy unlimited e-books, audiobooks & documents.Find out more
Download
Standard view
Full view
of .
Look up keyword
Like this
2Activity
0 of .
Results for:
No results containing your search query
P. 1
Cord Compression Case -- NCPs

Cord Compression Case -- NCPs

Ratings: (0)|Views: 94|Likes:
Published by Mhaii Ameril
NCPs of the Cord Compression Case. ;)
NCPs of the Cord Compression Case. ;)

More info:

Published by: Mhaii Ameril on Jan 23, 2011
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as DOCX, PDF, TXT or read online from Scribd
See more
See less

05/01/2012

pdf

text

original

 
ASSESSMENT NURSINGDIAGNOSISPLANNING IMPLEMENTATION EVALUATION
Subjective
:
³Makirot ang hiwa kosa tiyan, lalo na pagumuupo ako,´ asstated by the patient.8 out of 10 pain scaleObjective
:
Vital Signs
± BP ± 110/90 mmHgPR ± 80 bpmRR ± 24cpmTemp ± 37.4°C
 Incision Site
± Wound dressing intact
S/Sx
± Expressive behavior:irritability, facialgrimacingCovers the incisionsite (guarding behavior) No foul odor notedIncision site warm andreddened
Acute pain
 
related toabdominalincision asevidenced by8 out of 10 pain scaleWithin 20minutes of nursingintervention,the patient will be able to:
 
Participatein demo-nstratingtechniquesto relieve pain
 
V
erbalizeelimination/reduc-tion of  pain from8 to 4.
 INDEPENDENT DEPENDENT COLLABO- RATIVE 
A
fter 20 minutesof nursingintervention, theclient:Demonstrated participation intechniques torelieve pain(proper  positioning,resting, andfollowingnonpharmacologic pain regimens)
V
erbalizedreduction of painfrom 8 to 5Goal partiallymet.
Assess
:
 
A
ssess client¶s painscale (
to be able tomonitor progression of nursing interventions)
 
Monitor vital signsevery 4 hours
 Care
:
 
Provide calm, quietenvironment
 
Provide comfortmeasures such as back rub
(
to providenonpharmacologicalpain management)
 
 
Promote low Fowler¶s position (
low Fowler¶sposition reducesintraabdominalpressure, thus reducespain too)
 
 
Employ non- pharmacologic paindistraction such asmusic therapy, watchingtelevision, and talkingto SOs.
(
distraction of attention reduces painperception)
 
Teach
:
 
Teach client to eat fresh
 
A
dminister mefenamicacid q4°PO
(
takinganalgesicslessens thepain)
 
Encourage
 
fruits vegetables andalso to increase proteinand fluid intake in thediet
(
intake of foodsthat promote woundhealing hastenshealing of client¶swound, thus reduceand eliminate painfrom it)
 
Encourage adequate rest periods
(
to preventfatigue)
ambulationas soon as possibleafter birth
(
ambulationdecreasesvenousstasis andincreaseplateletsthatcanpromote woundhealing)
 
ASSESSMENT NURSINGDIAGNOSISPLANNING IMPLEMENTATION EVALUA-TION
Subjective:n/aObjective:
 Incision site
± 7 cm horizontalhypo-gastricincision withintact suturesOpen areamoderateamount of sero-saguineousdrainage No odor, skinaround erythe-matousPain 8 out of 10scale
Impairedskin integrity
 
related tosurgical incisionas evidenced by7 cm incisionaroundhypogastric area
A
fter 3 days of nursingintervention, the patient will beable to:Display gradualand timelyhealing on theincision siteParticipate in preventionmeasures thatcan hider woundhealing andtreatment program
 INDEPENDENT DEPENDENT COLLABO RATIVE 
A
fter 3 days of nursingintervention,the patient wasable to:Display gradualand timelyhealing on theincision site.Participate in preventionmeasures thatcan hinder wound healingand treatment program
Assess:
 
A
ssess the appearance, odor, anddrainage in the incision site
(
fordocumentation purposes andalso serves as the baseline datafor future comparison)Care:
 
Perform hand hygiene beforetouching the incision site
(
toprevent spread of micro-organisms)
 
eep the area of incision siteclean and dry, carefully dresswound, and support incision
(
toassist body¶s natural process of healing)
 
U
se appropriate wound coveringsand skin-protective agents
(
toprotect the wound andsurrounding areas/structuresfrom trauma, injury, andmicroorganisms)Teach:
 
A
ssist the client/SOs inunderstanding and followingmedical regimen and developing program of preventive care anddaily maintenance
(
enhancescommitment to plain,optimizing outcomes)
 
(with MD)
A
dministecephalexin500mg POq6° to preventinfection
 
(withnutritionist) Provideoptimumnutritionandincreased proteinintake to provide a positivenitrogen balance
(
to aid inhealingand to

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->