Drugs
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ASSESSMENT S> “Nahihirapan akong huminga”, as verbalized O> O2 inhalation via nasal cannula @ 3-4L/min Complain of chest pain With deep shallow breathing V/S as follows: BP-120/80mmHg RR-24cpm PR-64bpm Temp- 37.1C
DIAGNOSIS Risk for ineffective breathing pattern related to decreased lung expansion secondary to prolong sedation
PLANNING After 30 minutes of nursing interventions: a normal/ effective respiratory pattern will be established
INTERVENTION
RATIONALE
Position in moderate high back rest
To promote lung expansion
O2 inhalation via nasal cannula @ 3-4L/min administer
To maintain O2 demand
Closely observed for alteration in vital signs
To have baseline data and to assess if there is presence of respiratory distress
Auscultate chest
To note any presence of abnormal breath sounds
Assist in the use of relaxation techniques such as deep breathing exercises
To promote lung expansion
Maintained well ventilated environment
To reduce stress
EVALUATION After 30 minutes of nursing interventions a normal respiratory pattern was established
ASSESSMENT S> “Medyo mahina ako kumain”, as verbalized O> weight- 48.9 kg Weak in appearance Inadequate food intake
DIAGNOSIS Risk for altered nutrition related to decreased peristaltic movement secondary to present condition
PLANNING After 8 hours of nursing interventions an increased in appetite will be observed
INTERVENTION
RATIONALE
Encourage verbalization of feelings
To assess the knowledge of patient in eating
Determine ability to chew, swallow and taste
Factors that can affect ingestion/digestion of nutrients
Provide diet modifications such as: low fat diet, small frequent feedings with snack, and decreased dairy products
To prevent the increase production of stones
Encourage to choose foods that are appealing
To stimulate appetite
Provide oral care before/after meals
To promote comfort
EVALUATION After 8 hours of nursing interventions an increased in appetite was observed, as evidenced by verbalization of: “Medyo okay n akong kumain”.
Promote pleasant, relaxing environment including socialization
To reduce stress
Prevent/ minimize unpleasant odor/ sights
May have negative effect on appetite
Promote adequate/ timely fluid intake
Decreases possibility of early satiety
ASSESSMENT S> “Masakit ang tahi ko”, as verbalized O> moaning every time ask for pain severity With facial grimace Weak in appearance Pain scale: 8/10
DIAGNOSIS Severe pain related to surgical incision done
PLANNING After an hour of nursing interventions the pain will be lessen from 8/10 to 5/10
INTERVENTION
RATIONALE
Encourage verbalization of feelings
To assess the level of pain
Accept client’s description of pain
Pain is a subjective experience and cannot be felt by others
Observe non-verbal cues such as facial expression
Observations may not be congruent with verbal reports
Monitor vital signs
Usually altered in pain
Provide comfort measures such as change of position or backrub
To alleviate the pain
Encourage use of relaxation exercises such as deep breathing
To promote lung expansion
Provide quiet environment, calm activities
To lessen pain
EVALUATION After an hour of nursing interventions the pain was lessen from 8/10 to 5/10 as evidenced by active participation in nursing care rendered
Provide nonpharmacologic therapies: listening radio, reading books, and socialization with others
To divert the attention
Provide adequate rest periods
To prevent fatigue
If all of the above doesn’t work, administer analgesic: Diclofenac 75mg IV Q6
Analgesic can lessen the pain
DIAGNOSIS Risk for ineffective breathing pattern related to decreased lung expansion secondary to prolong sedation
PLANNING After 30 minutes of nursing interventions: a normal/ effective respiratory pattern will be established
INTERVENTION
RATIONALE
Position in moderate high back rest
To promote lung expansion
O2 inhalation via nasal cannula @ 3-4L/min administer
To maintain O2 demand
Closely observed for alteration in vital signs
To have baseline data and to assess if there is presence of respiratory distress
Auscultate chest
To note any presence of abnormal breath sounds
Assist in the use of relaxation techniques such as deep breathing exercises
To promote lung expansion
Maintained well ventilated environment
To reduce stress
EVALUATION After 30 minutes of nursing interventions a normal respiratory pattern was established
ASSESSMENT S> “Medyo mahina ako kumain”, as verbalized O> weight- 48.9 kg Weak in appearance Inadequate food intake
DIAGNOSIS Risk for altered nutrition related to decreased peristaltic movement secondary to present condition
PLANNING After 8 hours of nursing interventions an increased in appetite will be observed
INTERVENTION
RATIONALE
Encourage verbalization of feelings
To assess the knowledge of patient in eating
Determine ability to chew, swallow and taste
Factors that can affect ingestion/digestion of nutrients
Provide diet modifications such as: low fat diet, small frequent feedings with snack, and decreased dairy products
To prevent the increase production of stones
Encourage to choose foods that are appealing
To stimulate appetite
Provide oral care before/after meals
To promote comfort
EVALUATION After 8 hours of nursing interventions an increased in appetite was observed, as evidenced by verbalization of: “Medyo okay n akong kumain”.
Promote pleasant, relaxing environment including socialization
To reduce stress
Prevent/ minimize unpleasant odor/ sights
May have negative effect on appetite
Promote adequate/ timely fluid intake
Decreases possibility of early satiety
ASSESSMENT S> “Masakit ang tahi ko”, as verbalized O> moaning every time ask for pain severity With facial grimace Weak in appearance Pain scale: 8/10
DIAGNOSIS Severe pain related to surgical incision done
PLANNING After an hour of nursing interventions the pain will be lessen from 8/10 to 5/10
INTERVENTION
RATIONALE
Encourage verbalization of feelings
To assess the level of pain
Accept client’s description of pain
Pain is a subjective experience and cannot be felt by others
Observe non-verbal cues such as facial expression
Observations may not be congruent with verbal reports
Monitor vital signs
Usually altered in pain
Provide comfort measures such as change of position or backrub
To alleviate the pain
Encourage use of relaxation exercises such as deep breathing
To promote lung expansion
Provide quiet environment, calm activities
To lessen pain
EVALUATION After an hour of nursing interventions the pain was lessen from 8/10 to 5/10 as evidenced by active participation in nursing care rendered
Provide nonpharmacologic therapies: listening radio, reading books, and socialization with others
To divert the attention
Provide adequate rest periods
To prevent fatigue
If all of the above doesn’t work, administer analgesic: Diclofenac 75mg IV Q6
Analgesic can lessen the pain
