Ncp's (myoma).docx

(1)ASSESSMENT

SUBJECTIVE: “mag lisod kog ginhawa” as verbalized by the patient

OBJECTIVE: T: 36.7 C. PR: 85 bpm RR: 37 cpm BP: 150/90 mmhg With rapid and shallow respirations Breath sound: Wheezing Uses accessory muscles to aid in breathing

NURSING DIAGNOSSIS Ineffective airway clearance related to bronchospasm, decreased lung expansion secondary to asthma.

SCIENTIFIC BASIS

The physiologic changes in lung ventilation that occur during an acute asthma attack impair both lung expansion and emptying. Anxiety caused by hypoxia and dyspnea compounds the problem by increasing the respiratory rate. REF:  Brunner & Suddarth’s Medical Surgical Nursing 13th Edition.  Virtual Medical Centre (2002– 2018)

GOAL In span of 1 hour of nursing intervention The client will be able to establish an effective respiratory pattern so as to provide adequate ventilation as manifested by stabilizing respiratory rate,decreasing chest tightness, slight to no nasal flaring and decreasing usage of accessory muscles.

NURSING INTERVENTION Independent 1. Frequently assess respiratory rate, pattern, and breath sounds. Note manifestations of ineffective breathing.

RATIONALE

1. Early identification of ineffective respirations allows timely initiation of interventions.

2.Monitored vital signs

2. Tachypnea, tachycardia, an elevated blood pressure, and increasing hypoxemia and hypercapnia are signs of compromised respiratory status.

3. Assisted with selfcare activities.

3. This conserves energy and reduces fatigue.

4. Provided rest periods between scheduled activities and treatments

4. Scheduled rest is important to prevent fatigue and reduce oxygen demands.

5. Placed in High Fowler’s position

5. These positions reduce the work of breathing and increases lung

Exhibits nasal flaring

EVALUATION After 1hour of nursing interventions The client manifested decreasing respiratory rate, RR=22breaths/minute and appeared less strained and distressed upon breathing. However, wheezes can still be auscultated from all lung fields and there is still usage of accessory muscles and nasal flaring

expansion, especially the basilar areas. 6. instructed and assisted to use techniques to control breathing pattern: a. Pursed-lip breathing Dependent 7. Administered Salbutamol 1 neb c/o pulmo as ordered.

6. Pursed- lip breathing helps keep airways open by maintaining positive pressure, and abdominal

7. to opens up the medium and large airways in the lungs.

Collaboration 8. Monitored with 8. Necessary laboratory/diagnostic for management studies as indicated. of underlying and possible complications

(2)ASSESSMENT

SUBJECTIVE: “sakit akong tyan sa righ side dapit’ as verbalized by the patient. PS: 8/10

OBJECTIVE: VS follows: T: 36.7 C. PR: 85 bpm RR: 20 cpm BP: 140/90 mmhg  PAIN: 8/10  Guarding behaviour  Grimace face  Slightly irritable

NURSING DIAGNOSSIS Acute pain related to intrauterine tissue damage secondary to Uterine Myoma.

SCIENTIFIC BASIS

Uterine fibroids are benign smooth muscle tumors of the uterus. The exact cause is unclear. However, fibroids run in families and appear to be partly determined by hormone levels. Symptoms depend on the location and size of the fibroid. Important symptoms include abnormal uterine bleeding, heavy or painful periods, abdominal discomfort or bloating, painful defecation, back ache, urinary frequency or retention, and in some cases, infertility.

REF:  National Center for Biotechnology Information, U.S. National Library of Medicine

GOAL

After 1 hr of nursing interactions the patient able to relieve from pain -Patient will manifest signs of comfort -Patient will verbalize understanding of cause of pain.

NURSING INTERVENTION Independent 1. Acknowledge reports of pain immediately.

RATIONALE

EVALUATION

1. An immediate response to reports of pain may decrease anxiety in the patient.

After 1 hour of nursing intervention the client verbalizes minimize pain from 8 to 3 pain scale (partially goal met)

2. Monitor Vital sign

2. Alterations from normal maybe signs of infection.

3. Provide rest periods to promote relief, sleep, and relaxation.

3. A peaceful and quiet environment may facilitate rest.

4. Encourage diversional activities and relaxation techniques such as focused breathing and imaging

4. To distract attention and reduce tension

5. Encourage and assist client to do deep breathing exercises

5. Deep breathing exercises contribute to relief of pain

Dependent 6.administered hyoscine butylbromide as ordered by the physician.

6.To alleviate patient pain.

Collaboration 7. Assist with laboratory/diagnostic studies

7. Necessary for management

-The client demonstrates signs of comfort (goal met) -Patient able to verbalize understanding cause of pain. (goal met)

 Brunner & Suddarth’s Medical Surgical Nursing 13th Edition.

as indicated. (e.g., abdominalX-ray)

of underlying and possible complications

(3)ASSESSMENT

SUBJECTIVE: No verbal cues

OBJECTIVE: VS follows: T: 36.7 C. PR: 85 bpm RR: 20 cpm BP: 140/90 mmhg Slightly irritable (+) Dry lips (+) Pale Lab results: Erythrocytes (4.39) Lymphocytes (0.33) CBG (352 mg/dl)

NURSING DIAGNOSSIS

SCIENTIFIC BASIS

Diabetes mellitus Fatigue Is a group of metabolic related to diseases characterized decrease by increased levels of muscular glucose in the blood strength resulting from defects secondary in insulin secretion, to Diabetes insulin action, or both. Mellitus In type 2 diabetes, Type 1. people have decreased sensitivity to insulin and impaired beta cell functioning resulting in decreased insulin production. Glucose derived from food cannot be stored in the liver thereby remaining into the bloodstream. The beta cells of the islets of Langerhans release glucagon which stimulates the liver to release the stored glucose. After 8 ± 12 hours, the liverforms glucose from the breakdown of noncarboghydrate substances, including amino acids resulting to muscle wasting which results

GOAL After 2 to 3 hrs of nursing intervention patient will be able to identify measures to conserve and increase body energy.

NURSING INTERVENTION

RATIONALE

Independent 1.established rapport.

1.To build trust

2.Monitored VS.

2. baseline data

3. Assessed skin turgor and mucous membrane for sign of dehydration.

3. to monitor for signs of dehydration

4. encouraged patient to increase oral fluid intake,

4. to replace fluid loss and prevent dehydration

Dependent 5. Administered IVF as order by physician.

5. to replace fluid and electrolytes loss

6. Administered Insulin as ordered by physician.

6. to improve glycemic control

EVALUATION After 2 to 3 hrs of nursing intervention patient was able to identify measures to conserve and increase body energy. The patient was free or relieve from signs of fatigue.

REF:  Scrib  Brunner & Suddarth’s Medical Surgical Nursing 13th Edition.

(4)ASSESSMENT

NURSING DIAGNOSSI S

SCIENTIFIC BASIS

GOAL

NURSING INTERVENTION

Risk for blood volume deficit related to heavy menstruatio n secondary to Uterine Myoma.

Uterine polyps are formed by the overgrowth of endometrial tissue. They are attached to the endometrium by a thin stalk or a broad base and extend inward into the uterus. The polyps may be round or oval, and range in size from a few millimeters (the size of a sesame seed) to a few centimeters or larger. There may be one or several polyps present. Uterine polyps are usually benign (noncancerous), but they may cause problems with menstruation (periods) or fertility.

After 1hr of nursing intervention patient will have understanding about the present illness.

1. Establish rapport

Patient will have no signs of pale skin and dry lips

4. Weight patient daily

Independent SUBJECTIVE: “Kusog ang agas sa akon dugo basta dalaw na nako”

OBJECTIVE: T: 36.7 C. PR: 85 bpm RR: 20 cpm BP: 140/90 mmhg (+) Dry lips (+) Pale Lab results: Erythrocytes (4.39) Lymphocytes (0.33)

Patient will able to verbalize importance of proper blood volume on the body

2. Assess patient condition

3. Monitor vital signs

RATIONALE

After 1hr of nursing intervention patient the 2.to monitor other signs client was able and symptoms to verbalizes understanding 3. to obtain baseline of present data for pt. illness (goal met) 4, change in weight 1. to earn patient trust and cooperation

can provide information need for adequacy for blood volume replacement 5. Promote rest and planned activities

6. Encourage patient to eat green leafy vegetables

Dependent 7. Administered Intravenous fluid PNSS 1L @ 100ml/hr

5. plan care to alternate period of rest and activity without tiring the client 6. Green leafy vegetables facilitates cell production

7. for the replacement of fluid.

REF:  clevelandclinic.o rg  Medical Surgical Nursing, vol.2,

EVALUATION

Collaboration 8. Necessary 8. Assist with laboratory/diagnostic studies for management of underlying and as indicated. possible complications

The client shows normal skin color and moist lips(goal met) Patient able to verbalize importance of blood volume in the body (goal met)

9th edition, Brunner and Suddarths

(5)ASSESSMENT SUBJECTIVE: No verbal cues

OBJECTIVE: T: 36.7 C. PR: 85 bpm RR: 20 cpm BP: 140/90 mmhg (+) Dry lips (+) Pale Laboratory: Lymphocytes (0.33) Erythrocytes (4.39)

NURSING DIAGNOSSIS Risk for infection related to inadequate secondary defense as evidence by decreased lymphocytes

SCIENTIFIC BASIS

GOAL

Lymphocytes occur in two forms: B cells, which produce antibodies, and T cells, which recognize foreign substances and process them for removal

In span of 1hour of nursing interventions The patient will be free signs of any infection

NURSING INTERVENTION Independent 1.Assess the skin for color, texture, elasticity, and moisture.

The patient will be able to REF: demonstrate ability to perform  Encyclopaedia hygienic measures Britannica 2 Routinely monitor  Brunner & The patient will be the patient’s white Suddarth’s able to verbalize blood cell count Medical which symptoms of Surgical infection to watch Nursing 13th out for Edition 3. Encourage adequate rest

4. Encourage patient to eat a balanced diet.

RATIONALE

EVALUATION After 1 hour of nursing interventions the patient shall be free of any signs of infections( goal met )

1.Proper skin assessment and documentation facilitates prevention of the breakdown of skin breakdown which is the body’s first line Patient able to of defense againts demonstrate of pathogens. performing personal hygiene 2.These laboratory (goal met) values are closely linked to the The patient able to patient’s nutritional verbalize the signs status and immune and symptoms of function. any infection. (goal met) 3. It can reduce stress and boost the immune system. 4. A balanced intake of omega 3 and omega 6 fatty acids, protein, vitamins A, C and E, zinc and iron is essential in reducing risk of infection.

5. Limit the number of visitors allowed.

5. This is to limit the risk of the patient being exposed to pathogens.

Collaboration 6. Assist with 6. Necessary laboratory/diagnostic for management studies as indicated. of underlying and possible complications