8ncp.docx

Assessment Subjective: “Natatakot ako sakaramdaman ko”as verbalized bypatient.

Objective: • Increased tension. • Restlessness. • Hopelessness. •V/S taken as follows: T: 37.2 P: 92 R: 20 Bp: 110/90

Diagnosis Fear related to situational crisis.

Planning After 4 hours of nursing interventions, the patient will display appropriate range of feelings and lessened fear.

Interventions Rationale Independent: •Review patient’s •Clarifies patient’s previous experience perceptions and with cancer. assist in identification of fears and misconceptions based on diagnosis and experience with cancer. •Encourage patient to share thoughts and feelings.

•Provides opportunity to examine realistic fears and misconceptions about diagnosis.

•Maintain frequent contact with patient. Talk with and touch patient as appropriate.

•Provides assurance that patient is not alone or rejected and fostering trust.

•Provide accurate, consistent information regarding diagnosis and prognosis.

•Can reduce anxiety and enable patient to make decision and choices based on realities.

Evaluation After 4 hours of nursing interventions, the patient was able to display appropriate range of feelings and lessened fear.

•Explain procedures, providing opportunity for questions and honest answers.

•Accurate information allows patient to deal more effectively with the situation, thereby reducing anxiety and fear.

•Promote calm, quiet environment.

•Facilitates rest, conserves energy, and may enhance coping abilities.

Collaborative: •Refer for additional resources for counseling or support as needed. Reference:www.pdfcoke.com and nurseslabs.com Nursing Care Plan

•May be useful from time to time to assist patient in dealing with anxiety.

Assessment Subjective cues: “sakit akong luyo ug” as verbalized by the patient.

Objective cues: -Received patient lying on bed, awake, coherent, & responsive. -Limited ROM

Diagnosis Impaired physical mobility related to disease process (compression/destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation)

Planning After 8 hours of rendering appropriate nursing interventions the patient will be able to:

Interventions Independent  Assist patient to do active ROM exercises on the lower extremities.

Rationale 

To improve muscle strength and joint mobility



Assess degree of mobility produced by injury or treatment and note patient’s perception of immobility



Patient may be restricted by self-view or self- perception out of proportion with actual physical limitations requiring interventions to promote progress toward wellness.



Perform an assessment of pain to include location, characteristics , onset/ duration, frequency, quality, severity,



Indicates need for/ effectiveness of interventions and may signal development/resolution of complications.

1. Demonstrate increasing function of the extremities.

Evaluation After 8 hours of rendering appropriate nursing interventions the patient was able: 1. Demonstrate increasing function of the extremities.





grimacing ( 0 – 10 scale) Provide comfort measures, quiet environment and calm activities Encourage diversional activities and relaxation techniques such as focused breathing and imaging

Dependent  Administer analgesics as prescribed by the physician. Collaborative  Consult with physical or occupational therapist as indicated. Reference:www.pdfcoke.com and nurseslabs.com



To promote nonpharmacological pain management.



To distract attention and reduce tension



In order for the muscle to be more relax and relieves the pain



To develop individual exercise or mobility program and identify appropriate adjunctive devices.

Nursing Care Plan

Nursing Care Plan Assessment Subjective: The patient verbalized difficulty of urinating with a pain scale of 7 out of 10. Objectives: T= 36.2 C BP= 100/60mmHg P=67 bpm R=20 cpm (+) good skin turgor (+) moist mucous membranes (+) stable weight &VS (+) sunken eyes (+) conscious (+) clear speech

Diagnosis Impaired urinary elimination related to decreased urine output.

Planning After 8 hours of nursing intervention, the patient will reduce pain scale of 7 to 4.

Interventions 1. Record urinary output; investigate sudden reduction/cessation of urine flow.

Rationale Evaluation 1. Sudden decrease in Goal partially met. urine flow may indicate obstruction/dysfunction or dehydration.

2. Encourage increased fluids & maintain accurate fluids.

2. Maintain hydration & good urine flow.

3. Monitor BP & HR.

3. Orthostatic hypotension &tachycardia suggest hypovolemia.

4. Note urine flow & characteristics.

4. Decreased flowmay reflect urinary retention within crease pressure in Upper Urinary Tract.

5. Administer medication as indicated eg. Analgesic & antibiotcs

5. Relieve pain enhances comfort &promotes rest.

6. Monitor laboratory studies. Reference:www.pdfcoke.com and nurseslabs.com

6. To indicate urinalysis status.