Cnu-cn Form 002 Cebu Normal University College Of Nursing Cebu

CNU-CN FORM 002 Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion

NURSING CARE PLAN NCP Scoring System 10 pts Defining Characteristics 3 pts Intervention 3 pts

Nursing Dx 2 pts Outcome 1 pt Bibliography 1 pt

Client’s Name: Patient Care Classification: (Please check) Age: 23 Sex: F Civil Status: married Religion: roman catholic Wholly Compensatory: Pts. therapeutic selfcare isaccomplished by nurse Allergies: Food: none Partially Compensatory: Pt. performs some self-care measures Drug: none Supportive Educative: Pt. accomplishes self-care measures Diet: Clinical Division and Bed No. Female Medicare Bed 1 Date of Admission: October 5, 2009 Name of Physician: Dr. Isla Diagnosis: Disseminated Intravascular Coagulation Name of Student:

DEFINING CHARACTERISTICS Nursing Diagnosis:

EXPECTED OUTCOME CRITERIA

INTERVENTION AND RATIONALE

BEHAVIORAL OUTCOME

DEFINING CHARACTERISTICS

EXPECTED OUTCOME CRITERIA

INTERVENTION AND RATIONALE

BEHAVIORAL OUTCOME

ineffective tissue perfusion(specify) may be related to alteration of arterial/venous flow(microemboli throughout circulatory system and hypovolemia), possibly evidenced by changes in respiratory rate and depth, changes in mentation,decreased urinary output and development of acral cyanosis/focal gangrene defining characteristics: subjective objective desired outcomes verbalize understanding of condition, therapy regimen, side effects of medications, and when to contact healthcare provider

demonstrate behaviors or lifestyle changes to improve circulation

demonstrate increased perfusion as individually appropriate short term long term interventions independent 1.note costumary baseline data(bp,weight,mentation,ABG's and other appropriate laboratory values r: provides comparison with current findings s:(Doenges et al pg.708)

2.Review results of diagnostic studies r: to determine location or severity of condition s:(Doenges et al. 708) 3.auscultate bp,ascertain client's usual range r:decreased glomerular filtration rate may increase renin release and raise bp s:(Doenges et al. 708) 4.measure circumference of extremities,as indicated r: useful in identifying edema in involved extremity s: (Doenges et al. pg.709) 5.elevate head of bed at night r:to increase gravitational blood flow s:(Doenges et al. pg.711) 6.exercise caution in use of hot water bottles or heating pads r: tissues may have decreased sentivity due to ischemia and heat also increases the metabolic demands of already compromised tissues s:(Doenges et al. pg.711) 7.encourage smoking cessation, provide information r:smoking causes vasoconstriction and may further compromise perfusion s:(Doenges et al. pg.712) 8.discourage massaging of calf in presence of varicose veins r:to prevent embolization s:(Doenges et al. pg.712) 9.demonstrate use of relaxation techniques r: to decrease tension level

s:(Doenges et al. pg 712) 10.discuss individual risk factors r:information necessary for client to make informed choices about remedial risk factors and commitment to lifestyle changes, as appropriate to prevent onset of complications s:(Doenges et al. pg.712)

collaborative apply antithromboembolytic hose/compression bandages to lower extremities before arising from bed r: to prevent venous stasis s:(Doenges et al. pg.711) review medical regimen and appropriate safety measures r:to assess the knowledge of the patient s:(Doenges et al. pg.711) provide preoperative teaching appropriate for the situations r:more information results to compliance in therapeutic interventions s:(Doenges et al. pg.713)

CNU-CN FORM 002 Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion

NURSING CARE PLAN NCP Scoring System 10 pts Defining Characteristics 3 pts Intervention 3 pts

Nursing Dx 2 pts Outcome 1 pt Bibliography 1 pt

Client’s Name: Patient Care Classification: (Please check) Age: 23 Sex: F Civil Status: married Religion: roman catholic Wholly Compensatory: Pts. therapeutic selfcare isaccomplished by nurse Allergies: Food: none Partially Compensatory: Pt. performs some self-care measures Drug: none Supportive Educative: Pt. accomplishes self-care measures Diet: Clinical Division and Bed No. Female Medicare Bed 1 Date of Admission: October 5, 2009 Name of Physician: Dr. Isla Diagnosis: Disseminated Intravascular Coagulation Name of Student:

DEFINING CHARACTERISTICS Nursing Diagnosis:

EXPECTED OUTCOME CRITERIA

INTERVENTION AND RATIONALE

BEHAVIORAL OUTCOME

DEFINING CHARACTERISTICS

EXPECTED OUTCOME CRITERIA

INTERVENTION AND RATIONALE

BEHAVIORAL OUTCOME

acute pain may be related to bleeding into joints/muscles, with hematoma formation, and ischemic tissues with areas of acral cyanosis/focal gangrene, possibly evidenced by verbal reports, narrowed focus, alteration in muscle tone, guarding/distraction behaviors, restlessness,autonomic responses defining characteristics: Patient reports pain * Guarding behavior, protecting body part * Self-focused * Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact) * Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness) * Facial mask of pain * Alteration in muscle tone: listlessness or flaccidness; rigidity or tension * Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea) subjective objective desired outcomes report pain is relieved

follow prescribed pharmacological regimen

verbalize non pharmacologic methods that provide relief

demonstrate use of relaxation skills and diversional activities as indicated for individual situation short term long term interventions independent Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus. r:Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain. S:(nursingcareplan.blogspot.com) * Assess for probable cause of pain. R:Different etiological factors respond better to different therapies. S:(nursingcareplan.blogspot.com) * Assess patient’s knowledge of or preference for the array of pain-relief strategies available. R:Some patients may be unaware of the effectiveness of nonpharmacological methods and may be willing to try them, either with or instead of traditional analgesic medications. Often a combination of therapies (e.g., mild analgesics with distraction or heat) may prove most effective. S:(nursingcareplan.blogspot.com) * Evaluate patient’s response to pain and medications or therapeutics aimed at abolishing or relieving pain. R:It is important to help patients express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures. Discrepancies between behavior or appearance and what patient says about pain relief (or lack of it) may be more a reflection of other methods patient is using to cope with than pain relief itself. S:(nursingcareplan.blogspot.com) * Assess to what degree cultural, environmental, intrapersonal, and intrapsychic factors may contribute to pain or pain relief.

R:These variables may modify the patient’s expression of his or her experience. For example, some cultures openly express feelings, while others restrain such expression. However, health care providers should not stereotype any patient response but rather evaluate the unique response of each patient. S:(nursingcareplan.blogspot.com) * Evaluate what the pain means to the individual. R:The meaning of the pain will directly influence the patient’s response. Some patients, especially the dying, may feel that the "act of suffering" meets a spiritual need. S:(nursingcareplan.blogspot.com) * Assess patient’s expectations for pain relief. R:Some patients may be content to have pain decreased; others will expect complete elimination of pain. This affects their perceptions of the effectiveness of the treatment modality and their willingness to participate in additional treatments. S:(nursingcareplan.blogspot.com) * Assess patient’s willingness or ability to explore a range of techniques aimed at controlling pain. R:Some patients will feel uncomfortable exploring alternative methods of pain relief. However, patients need to be informed that there are multiple ways to manage pain. S:(nursingcareplan.blogspot.com) * Anticipate need for pain relief. R:One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount of analgesic required. S:(nursingcareplan.blogspot.com) * Respond immediately to complaint of pain. R:In the midst of painful experiences a patient’s perception of time may become distorted. Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patient’s welfare and comfort fosters the development of a trusting relationship. S:(nursingcareplan.blogspot.com) * Eliminate additional stressors or sources of discomfort whenever possible.

R: Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them. S:(nursingcareplan.blogspot.com) * Provide rest periods to facilitate comfort, sleep, and relaxation. R:The patient’s experiences of pain may become exaggerated as the result of fatigue. In a cyclic fashion, pain may result in fatigue, which may result in exaggerated pain and exhaustion. A quiet environment, a darkened room, and a disconnected phone are all measures geared toward facilitating rest. S:(nursingcareplan.blogspot.com) * Determine the appropriate pain relief method. 1. Pharmacological methods include the following: Nonsteroidal antiinflammatory drugs (NSAIDs) that may be administered orally or parenterally (to date, ketorolac is the only available parenteral NSAID). 2. Use of opiates that may be administered orally, intramuscularly, subcutaneously, intravenously, systemically by patient-controlled analgesia (PCA) systems, or epidurally (either by bolus or continuous infusion). Narcotics are indicated for severe pain, especially in the hospice or home setting. 3. Local anesthetic agents.

Collaborative Determine the appropriate pain relief method. 1. Pharmacological methods include the following: Nonsteroidal antiinflammatory drugs (NSAIDs) that may be administered orally or parenterally (to date, ketorolac is the only available parenteral NSAID). 2. Use of opiates that may be administered orally, intramuscularly, subcutaneously, intravenously, systemically by patient-controlled analgesia (PCA) systems, or epidurally (either by bolus or continuous infusion). Narcotics are indicated for severe pain, especially in the hospice or home setting. 3. Local anesthetic agents. S:(nursingcareplan.blogspot.com) * Give analgesics as ordered, evaluating effectiveness and observing for any signs and symptoms of untoward effects. •

R:Pain medications are absorbed and metabolized differently by patients, so their effectiveness must be evaluated from patient to patient. Analgesics may cause side effects that range from mild to life-threatening.

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S:(nursingcareplan.blogspot.com)

laboratory findings theoretical basis

CNU-CN FORM 002 Cebu Normal University College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion

NURSING CARE PLAN NCP Scoring System 10 pts Defining Characteristics 3 pts Intervention 3 pts

Nursing Dx 2 pts Outcome 1 pt Bibliography 1 pt

Client’s Name: Patient Care Classification: (Please check) Age: 23 Sex: F Civil Status: married Religion: roman catholic Wholly Compensatory: Pts. therapeutic selfcare isaccomplished by nurse Allergies: Food: none Partially Compensatory: Pt. performs some self-care measures Drug: none Supportive Educative: Pt. accomplishes self-care measures Diet: Clinical Division and Bed No. Female Medicare Bed 1 Date of Admission: October 5, 2009 Name of Physician: Dr. Isla Diagnosis: Disseminated Intravascular Coagulation Name of Student:

DEFINING CHARACTERISTICS Nursing Diagnosis:

EXPECTED OUTCOME CRITERIA

INTERVENTION AND RATIONALE

BEHAVIORAL OUTCOME

DEFINING CHARACTERISTICS

EXPECTED OUTCOME CRITERIA

INTERVENTION AND RATIONALE

BEHAVIORAL OUTCOME

anxiety(specify level)/fear may be related to sudden change in health status/threat of death,interpersonal transmission/contagion, possibly evidenced bysympathetic stimulation, restlessness, focus on self and apprehension defining characteristics: subjective objective desired outcomes appear relaxed and report anxiety is reduced to a manageable level

verbalize awareness of feelings of anxiety

identify healthy ways to deal with and express anxiety

demonstrate problem solving skills

use resources or support systems effectively short term long term interventions independent

* Determine how patient copes with anxiety. This can be done by interviewing the patient. R:This assessment helps determine the effectiveness of coping strategies currently used by patient. S:(nursingcareplan.blogspot.com) * Suggest that the patient keep a log of episodes of anxiety. Instruct patient to describe what is experienced and the events leading up to and surrounding the event. Patient should note how the anxiety dissipates. R:Patient may use these notes to begin to identify trends that manifest anxiety. S:(nursingcareplan.blogspot.com) * Acknowledge awareness of patient’s anxiety. R:Because a cause for anxiety cannot always be identified, the patient may feel as though the feelings being experienced are counterfeit. Acknowledgment of the patient’s feelings validates the feelings and communicates acceptance of those feelings. S:(nursingcareplan.blogspot.com) * Reassure patient that he or she is safe. Stay with patient if this appears necessary. R:The presence of a trusted person may be helpful during an anxiety attack. S:(nursingcareplan.blogspot.com) * Maintain a calm manner while interacting with patient. The health care provider can transmit his or her own anxiety to the hypersensitive patient. R:The patient’s feeling of stability increases in a calm and nonthreatening atmosphere. S:(nursingcareplan.blogspot.com) * Establish a working relationship with the patient through continuity of care. R: An ongoing relationship establishes a basis for comfort in communicating anxious feelings. S:(nursingcareplan.blogspot.com) * Orient patient to the environment and new experiences or people as needed.

R:Orientation and awareness of the surroundings promote comfort and may decrease anxiety. S:(nursingcareplan.blogspot.com) * Use simple language and brief statements when instructing patient about selfcare measures or about diagnostic and surgical procedures. R:When experiencing moderate to severe anxiety, patients may be unable to comprehend anything more than simple, clear, and brief instructions. S:(nursingcareplan.blogspot.com) * Encourage patient to seek assistance from an understanding significant other or from the health care provider when anxious feelings become difficult. R:The presence of significant others reinforces feelings of security for the patient. S:(nursingcareplan.blogspot.com) * Assist the patient in developing anxiety-reducing skills (e.g., relaxation, deep breathing, positive visualization, and reassuring self-statements). R:Using anxiety-reduction strategies enhances patient’s sense of personal mastery and confidence. S:(nursingcareplan.blogspot.com) * Assist patient in developing problem-solving abilities. o Emphasize the logical strategies patient can use when experiencing anxious feelings. R:Learning to identify a problem and evaluate alternatives to resolve it helps the patient to cope. S:(nursingcareplan.blogspot.com)

* Assist patient in recognizing symptoms of increasing anxiety; explore alternatives to use to prevent the anxiety from immobilizing her or him. •

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R:The ability to recognize anxiety symptoms at lower-intensity levels enables the patient to intervene more quickly to manage his or her anxiety. Patient will be able to use problem-solving abilities more effectively when the level of anxiety is low. S:(nursingcareplan.blogspot.com)

collaborative • • • • •

* Instruct patient in the proper use of medications and educate him or her to recognize adverse reactions. R: Medication may be used if patient’s anxiety continues to escalate and the anxiety becomes disabling. S:(nursingcareplan.blogspot.com) * Instruct the patient in the appropriate use of antianxiety medications. R:to minimize the risk of overdosage and drug abuse S:(nursingcareplan.blogspot.com)

laboratory findings theoretical basis