ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE:
“sobrang sakit ng ulo Knowledge After 8 hours of 1. Assess patient’s level of 1. Facilitates planning of preoperative After 8 hours of
ko” as verbalized by deficiency related proper Nursing understanding. teaching program, identifies content proper Nursing
the patient. to unfamiliarity Intervention the 2. Review specific pathology and needs. Intervention the
with information patient will Verbalize anticipated surgical procedure. 2. Provides knowledge base from which patient Verbalized
OBEJECTIVE: resources as understanding of Verify that appropriate consent has patient can make informed therapy understanding of
 Left sided evidenced by the disease been signed. choices and consent for procedure and disease
weakness. statement of the process/perioperative 3. Use resource teaching materials, presents opportunity to clarify process/perioperative
 Right frontal problem/concerns, process and audiovisuals as available. misconceptions. process and
intracranial misconceptions. postoperative 4. Preoperative instructions: NPO time, 3. Specifically designed materials can postoperative
hemorrhage. expectations. shower or skin preparation, which facilitate the patient’s learning. expectations.
 GCS OF 15 routine medications to take and hold, 4. Helps reduce the possibility of GOAL MET
 VITAL prophylactic antibiotics, or postoperative complications and
SIGNS AS anticoagulants, anesthesia promotes a rapid return to normal body
FOLLOWS: premedication. function. Note: In some instances,
BP- 130/79 5. Intraoperative patient safety: not liquids and medications are allowed up
mmHg crossing legs during procedures to 2 hr before scheduled procedure.
PR- 63 BPM performed under local or light 5. Reduced risk of complications or
RR- 20 anesthesia. untoward outcomes, such as injury to
Oxygen sat- 6. Discuss individual postoperative the peroneal and tibial nerves with
98% pain management plan. Identify postoperative pain in the calves and feet.
misconceptions patient may have 6. Increases likelihood of successful pain
and provide appropriate information. management. Some patients may expect
7. Provide opportunity to practice to be pain-free or fear becoming
coughing, deep-breathing, and addicted to narcotic agents.
muscular exercises. 7. Enhances learning and continuation of
activity postoperatively.
 NAME CLASSIFICATI MECHANISM OF ACTION INDICATIONS SIDE EFFECTS NURSING RESPONSIBILITIES
ON
Generic: Therapeutic:  Increases the osmotic pressure Adjunct in the CNS: Before:
Mannitol Diuretics of the glomerular filtrate, treatment of: Confusion, headache  Check vital signs and urine output.
thereby inhibiting reabsorption  Acute oliguric renal  Assess signs of dehydration and muscle
Brand: Pharmacologic: of water and electrolytes. failure EENT: weakness.
Osmitrol, Resectisol Osmotic diuretic  Causes excretion of: water,  Edema Blurred vision, Rhinitis  Monitor neurologic status and intracranial
sodium, potassium, chloride,  Increased pressure.
calcium, phosphorus, intracranial or CV:
magnesium, urea, uric acid intraocular pressure. Transient volume expansion,
 Toxic overdose Chest pain, CHF, pulmonary During:
Therapeutic effects: edema, tachycardia  Administer over 30min.
 Mobilization of excess fluid  Monitor urine output and refer in accordance
in oliguric renal failure or CONTRAINDICATIONS GI: with parameters set by physician.
edema.  Hypersensitivity Nausea, thirst, vomiting  Ensure safety and report signs of electrolyte
 Reduction of intraocular or  Anuria imbalance.
intracranial pressure. GU:
 Dehydration
 Increased urinary excretion of  Active Intracranial renal failure, urinary
toxic materials. retention After
bleeding
 Decreased hemolysis when  Use cautiously in:  Check effectiveness of therapy.
used as an irrigant after F&E:
 Pregnany &  Continuously monitor neurologic status and
transurethral prostatic resection Dehydration, hyperkalemia,
lactation urine output
hypernatremia, hypokalemia,
hyponatremia  Reassess signs/symptoms of dehydration.
 Watch out for abnormal responses
Local:
Phlebitis@ IV site