Nursing Diagnosis # 1
Ne ed
Desired Outcome
Acute pain related to abdominal incision. Subjective cues:
P H Y S I O L O G I C
Within the 8 hours of duty, the patient should be able to:
“Sakit pa pero hindi na kaayo” as verbalized by the patient. Objective cues: Temp: 37.5 °C PR: 63 bpm RR: 19 cpm BP: 120/80 mm Hg
Rated pain as 4 to 6 out of 0 to 10 pain scale. Pain increases when moves vigorously Incision site:
N E E D
Report pain is relieved or controlled. Pain intensity 4 to 6 will decrease at 2 to 3 from 0 to 10 pain scale.
Nursing Intervention
Rationale
Evaluation
Modification
INDEPENDENT •
EEstablish rapport to the patient
MMonitor Vital signs
PPerform bedside care
To have baseline data and for comparison for future data
OObserve and document location, severity and character of pain.
To enhance patient’s self esteem and to provide comfort to the patient
To easily gain cooperation form the patient
GOAL MET. No The patient modifications was able to needed report the characteristic s of pain (location: right hypochondria c region, scaled pain as 4 to 6 out of 0 to 10 pain scale, able to verbalized pain felt upon pressure applied on the site). Able to verbalize feeling of comfort after repositioning was done.
Rationale
By getting the following information, we are asssitting in differentiating cause of pain and providing information about disease progression/resolutio n, development of complications and effective interventions.
Wound: dry, no discharges noted Dressing and plaster were clean and fully covered the incision site . No foul odor noted on the site.
BACKGROUND KNOWLEDGE:
Pain is defined as unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. (International Association for the Study of Pain); sudden
PPromote bedrest, allowing patient to assume position of comfort
CControl environment temperature
This also provides an objective means of evaluating the subjective experince of the patient. Bedrest in lowfowler’s posiiton reduces intraabdominal pressure; however, patient will naturally assume least painful position.
Cool surrounding aids in minimizing
or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of greater than 6 months. (Nurse’s Pocket Guide) The patient, report pain felt at the plantar region of left foot.. This affects the ability of the patient to take adequate rest for fast recovery. With this, it needs immediate nursing interventions to atleast reduce or lessen the pain. Nursing Diagnosis #2
dermal discomfort. .
TTake time to listen to and maintain frequent contact with patient and encourage to verbalize felelingf.
This is helpful in alleviating anxiety and reducing attention which could aid in relieving pain.
Verbalization of feeling can reduce perception intensity of pain. Thus would facilitate in providing comfort and relaxation.
Ne ed
Desired Outcome
Nursing Interventions
Evaluation statement
Nursing modifications
Rationale
Impaired skin integrity related to Subjective: Patient verbalized, “ Hapdos ang samad sa akong tiil” Objective: Temp: 37.5 °C PR: 63 bpm RR: 19 cpm BP: 120/80 mm Hg
• •
Disruption of skin surfaces Destruction of skin layer
P H Y S I O L O G I C
Within the eight hours of duty, the client will be able to: Understand the preventive measures give.
Establish rapport Establish rapport
Monitor vital signs
N E E D Perform bedside care
.
Inspect skin on daily basis and obseve for changes and unusualities
To have baseline data and for comparison for future data
To enhance patient’s self esteem and to provide comfort to the patient
To determine unusual ties and report it to physician for prompt treatment.
Goal met. As evidenced by verbalization of understanding on the preventive measures given.
No modification needed.
BACKGROUND KNOWLEDGE: Skin is the body’s first line of defense against foreign materials that can be considered as injuring agents. The appearance and the skin integrity are influenced by internal factors such as genetics, age and the underlying history of the individual as well as external factors such as activity. Once the skin is disrupted, this will put a person at risk since it may become a good medium for bacterial growth. Post-operative wound is closely noted and monitored for any unusualties since this is a risk factor that may lead the post-operative client in acquiring infection.
Keep the area clean, carefully dress wound, support incison, prevent infection
This will assist body’s natural process of repair
Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully
Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin
Emphasized importance of adequate nutrition and fluid intake
Improved nutrition and hydration will improve skin condition
To promote Assist the patient in wellness. understanding and following medical regimen.
Reference: Nurse’s Pocket Guide 11th Editon Doenges
Need
Desired Outcome
Nursing Interventions
Rationale
Nursing Diagnosis #3 Altered Physical Mobility related to pain secondary to unhealed wound on the plantar region of left foot. Subjective: “Gasakit akong tiil kung maglihok-lihok ko” Objectives: Temp:
37.5 °C PR: 63 bpm RR: 19 cpm BP: 120/80 mm Hg
Difficulty of
P H Y S I O L O G I C N E E D
Within the Establish rapport entire rotation, the client will be able to: Monitor vital signs
Perform bedside care .
To easily gain cooperation form the patient
To have baseline data and for comparison for future data To enhance patient’s self esteem and to provide comfort to the patient
Provide different methods So that she will be and teachings on pain knowledgeable upon the control measures. proper pain management technique Instruct client in safety To prevent accidents measuers, as that may add to the indicated:
Evaluation statement
Nursing modification s
Rationale
moving the lower extremities Background knowledge Limitation in independent, purposeful physical movement of the body or of one or more extremities Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma,
• Mmaintain lightning
injury of the patient
• Rreduce risk for falls by raising the side rails Encourage active and passive exercise that To increase stamina the patient can tolerate and endurance
morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation facilities or sent home for physical therapy in the home environment. Reference: Nurse’s Pocket Guide 11th Editon Doenges