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related to surgical incisions. Taxonomy: COGNITIVE-PERCEPTUAL PATTERN Cause Analysis: CUES Subjective: “Gasakit pa jud kayo akong tiyan kay bag-o lang ko nanganak…” STO: After 2-4 hours of giving nursing interventions, the patient’s pain decreases on a pain scale of 1-10 with pain less than 2, as evidence of the absence of facial grimace and feeling of relaxation. OBJECTIVES NURSING INTERVENTION Independent: Reassure patient that you know pain is real and will assist her in dealing with it. Assess and record pain and its characteristics, location, quality, frequency and duration. Encourage relaxation exercise such as deep breathing exercise when pain occurs. Review factors that aggravate or alleviate pain. Provide comfort measures and diversional activities and promote bed rest, allowing the patient to assume of comfort. Fear that pain will not be accepted as real increases tensions, anxiety and decreases pain tolerance. Data assist in evaluating pain and pain relief and identifying multiple sources and types of pain. Promotes relaxation, refocuses attention, and may enhance coping abilities. Helpful in establishing diagnosis and treatment needs. This contributes pain, relief muscle tension and anxiety whenever patient naturally assume least painful position. RATIONALE
Objective: >Facial grimace >General Weakness >Restlessness LTO: After 8 hours of giving effective nursing intervention, the patient’s level of pain is 0 and is able to sleep or rest appropriately.
Dependent: Prove and implement prescribe dietary medications. Administer medications if indicated. e.g., Analgesics
Patient may receive nothing by mouth (NPO) initially. When oral intake is allowed, food choices depend of the diagnosis. Analgesics are more effective
if administered early in pain cycle.
NURSING CARE PLAN
Problem Identified: bilateral flank pain Nursing Diagnosis: Acute Pain r/t biological injuring agent: inflammatory process secondary to Urinary Tract Infection Taxonomy: Cognitive-Perceptual Pattern Cause Analysis: Fluid shifts from the intravascular to the interstitial spaces as a result of the release of vasoactive amines by inflammatory process. It causes the nerve endings to be compress hence resulting in excruciating pain. Reference: Medical Surgical Nursing 10th Edition Volume 2 by Smeltzer and Bare
Subjective: “Sakit gyud akoang mga kiliran diri sa luyo” as verbalized by Pt
Short term objectives: Within 8 hours of interventions, the pt. will be able to verbalize a relief or control from pain.
Independent Observe and document location, severity (0–10 scale), and character of pain (e.g., steady, intermittent, colicky).
P – pain upon movement Q – sharp sensation R – bilateral flank Long term objectives: S – 3/10-4/10 Within 3 days of giving effective nursing T – pain lasts for a maximum of 20-40 interventions, the patient will be able to seconds verbalize relief of pain and to demonstrate use of relaxation skills and diversional activities as indicated for individual situation. Objective: • facial grimace • Weakness
Independent Assists in differentiating cause of pain, and provides information about disease progression/resolution, development of complications, and effectiveness of interventions. Severe pain not relieved by routine measures may indicate developing complications/need for further intervention. Bedrest in low-Fowler’s position reduces intra-abdominal pressure; Patient will naturally assume least painful position. Cool surroundings aid in minimizing dermal discomfort. Promotes rest, redirects attention, may enhance coping.
Note response to medication, and report to physician if pain is not being relieved. Promote bedrest especially in low-fowler’s position Allow patient to assume position of comfort. Control environmental temperature. Encourage use of relaxation techniques, e.g., guided imagery, visualization, deepbreathing exercises. Provide diversional activities. Make time to listen to and maintain frequent contact with patient.
Helpful in alleviating anxiety and refocusing attention, which can relieve
pain. Collaborative Administer Mefenamic Acid 250 mg po Collaborative Management of mild to moderate pain q8h, prn for pain Reference: Nursing Care Plans 6th Ed. by Doenges
NURSING CARE PLAN
PROBLEM: Anxiety NURSING DIAGNOSIS: Anxiety related to illness secondary to hypertension TAXONOMY: Self Perception Concept Pattern CAUSE ANALYSIS: Anxiety is common reaction to stress, a state of mental uneasiness, apprehension, or feeling of helplessness related to impending or unidentified threat to self or significant relationship.
CUES OBJECTIVES NURSING INTERVENTION RATIONALE EXPECTED OUTCOME
INDEPENDENT: SUBJECTIVE: “Sige ko ug hunahuna sa akong kahimtang karon” verbalized by the patient. STO: After 8 hours of giving nursing interventions the patient will be able to lessen or decrease as evidenced by expressing feelings regarding the situation. >Assure patient of confidentiality within limits of situation. >Maintain frequent contact with patient, talk with and touch patient. >Provide reliable and consistent information and support for S.O. >Encourage in guided imagery/ relaxation techniques such as OBJECTIVE: LTO: deep breathing and socializing After 3 days of giving nursing with S.O. >Fear of unspecific intervention the patient will be consequences. able to verbalized awareness of DEPENDENT: >restless feeling and healthy ways to >the patient appear tensed deal with them and demonstrate >Administer antianxiety & anxious decreasing level of anxiety. medication as needed. >provides reassurance and opportunity for patient to problem solve solutions to anticipated situations. >Provide assurance that patient is not alone or rejected: conveys respect for and acceptance of the person, fostering trust. >Allow for better interpersonal interaction and reduction of anxiety and fear. >Moderate anxiety heightens awareness and can help motivate patient to focus on dealing with problems. >May be useful for brief After 8 hours of giving nursing interventions the patient was able to lessen or decrease as evidenced by expressing feelings regarding the situation.
After 3 days of giving nursing intervention the patient was able to verbalized awareness of feeling and healthy ways to deal with them and demonstrate decreasing level of anxiety.
>BP – 160/120.
periods of time to help patient handle feelings of anxiety related to diagnoses and personal situation.
Mindanao Sanitarium and Hospital College Department of Nursing NURSING CARE PLAN
Name:_____________________ Age:_____ Gender:_______ Chief Complaints: ____________ Room No.:______________ Problem Identified: Grieving Nursing Diagnosis: Grieving related to loss of child Cause Analysis: Grief is emotional response of losing someone, feeling of helplessness related to impending significant relationship. CUES Objective cues: Crying Anger Guilt Feelings of sorrow Denial of loss OBJECTIVES STO: After 2 hrs of providing open environment in w/c patient feels free to realistically discuss feelings and concerns, the patient will be able to be freely discussed her feelings and concerns. LTO: After 2 weeks of discussing healthy ways of dealing w/ difficult situations, the patient will be able to slowly cope-up w/ grieving. NURSING INTERVENTION Independent 1.provide open environment in w/c patient feels free to realistically discuss feelings and concerns RATIONALE 1. Therapeutic communication skills such as active-listening silence, being available, in acceptance provide opportunity and encourage patient to talk freely and deal w/ the perceived/ actual loss. 2. Awareness allows for appropriate choice of interventions because individuals handle grief in many different ways. 3. The process of grieving does not proceed in an orderly fashion, but fluctuates w/ various aspects of all stages present at onetime or another. If process is dysfunctional or prolonged, more aggressive interventions may be required to facilitate the process. 4. Identification of problems Evaluation
2. Identify stage of grieving and effects on functioning: denial, anger, bargaining, depression, and acceptance. 3. Active-listen to patient’s concerns and be available for help as necessary.
4. Assess needs of SO and assist
as indicated. 5. Discuss healthy ways of dealing w/ difficult situation. Collaborative: 1. Refer to other resources, e.g. support groups, counseling, spiritual/pastoral care, psychotherapy as indicated. Reference: Nusing Care Plans 6th ed. By Doenges
indicating dysfunctional grieving allows for individual interventions 5. Provides opportunity to look toward the future and plan family’s/ SO’s needs. 1. May need additional help to resolve grief, make plans and look toward the future.
Mindanao Sanitarium and Hospital College Department of Nursing NURSING CARE PLAN Name:_____________________ Age:_____ Gender:_______ Chief Complaints: ____________ Room No.:______________ Problem Identified: Anxiety Nursing Diagnosis: Anxiety related to fear of possible loss of child Cause Analysis: Anxiety is an emotional reaction to the perception of reality that is experience physiologically, psychologically and behaviorally. (Psychiatric Nursing p.318) CUES Subjective Cues: “Abi naku mamatay to siya, abi jud naku dili masalo”, as verbalized by the client. Objective Cues: 23 cpm 100/70 mmhg Uneasiness Apprehension Feeling of helplessness OBJECTIVES STO: After 2 hrs of providing open environment in which patient feels safe to discuss feelings, the patient will be able to openly discuss her concerns. LTO: After 2-3 days of identifying and encouraging patient interaction with support systems, the patient will be able to slowly cope-up with her anxiety. NURSING INTERVENTION Independent: 1. Assure patient of confidentiality within limits of situation. 2. Provide open environment in which patient feels safe to discuss feelings or to refrain from talking. 3. Identify and encourage patient interaction with support systems. Encourage verbalization/interaction with family/SO. 4. Provide reliable and consistent information and support for SO. 5. Include SO as indicated when major decisions are to be made. RATIONALE 1. Provides reassurance and opportunity for patient to problem-solve solutions to anticipated situations. 2. Helps patient feel accepted in present condition without feeling judged, and promotes sense of dignity and control. 3. Reduces feelings of isolation. 4. Allows for better interpersonal interaction and reduction of anxiety and fear. 5. Ensures a support system for patient, and allows SO the chance to participate in patient’s life. 1. May require further assistance in dealing with Evaluation
1. Refer to psychiatric counseling. Reference: Nusing Care Plans 6th ed. By Doenges
diagnosis/prognosis, especially when suicidal thoughts are present.