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  • Ranking 1

    Transféré par

    Allain Banjo Mariano
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    1. The patient has disturbed body image related to having a T-tube attached after breast cancer surgery, ranking it as the second priority problem. She feels ashamed to go outside with it attached and has low self-esteem due to the perceived change in her appearance. 2. Acute pain related to the skin disruption and invasive T-tube procedure is ranked as the top priority problem. The patient reports pain, especially with movement or cold weather, and displays guarding behavior and a pain scale rating of 8/10. This problem requires the most immediate solution. 3. Risk for infection from the open wound where the T-tube was placed is ranked third as it is currently just a potential problem and not

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    1. The patient has disturbed body image related to having a T-tube attached after breast cancer surgery, ranking it as the second priority problem. She feels ashamed to go outside with it attached and has low self-esteem due to the perceived change in her appearance. 2. Acute pain related to the skin disruption and invasive T-tube procedure is ranked as the top priority problem. The patient reports pain, especially with movement or cold weather, and displays guarding behavior and a pain scale rating of 8/10. This problem requires the most immediate solution. 3. Risk for infection from the open wound where the T-tube was placed is ranked third as it is currently just a potential problem and not

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    Attribution Non-Commercial (BY-NC)
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    Signaler comme contenu inapproprié
    89 vues1 page

    Ranking 1

    Transféré par

    Allain Banjo Mariano
    1. The patient has disturbed body image related to having a T-tube attached after breast cancer surgery, ranking it as the second priority problem. She feels ashamed to go outside with it attached and has low self-esteem due to the perceived change in her appearance. 2. Acute pain related to the skin disruption and invasive T-tube procedure is ranked as the top priority problem. The patient reports pain, especially with movement or cold weather, and displays guarding behavior and a pain scale rating of 8/10. This problem requires the most immediate solution. 3. Risk for infection from the open wound where the T-tube was placed is ranked third as it is currently just a potential problem and not

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 1

    434 D Problem Identification and Prioritization

    Rankin Problems Identified Justification


    g
    2 Disturbed body image related to T- Self esteem is ranked 4th in Maslow’s
    tube attached to patient Hierarchy of needs which include the need
    for a person to feel good about herself.
    Subjective cue:
    (Fundamentals of Nursing, Taylor, 5th
    - “hindi pa ako makakalabas
    ng bahay pag uwe namin edition, p.28)
    kasi nahihiya akong makita
    ng ibang tao itong nakakabit The full impact of losing a breast or having
    sa akin” breast cancer may not be felt until a while
    after the client goes home. Individual
    Objective cues: women cope differently; feelings of sexual
    - Perceived change in in adequacy, poor body image, and loss of a
    appearance sense of feminity are common. (Medical
    - Low self esteem Surgical Nursing, Black, 8th edition, p. 955)

    1 Acute Pain related to interruption in This is 1st priority among the identified
    skin layers and invasive procedure ( problems because it is under physiologic
    T-Tube) as evidenced by verbal needs and an actual problem. It is also the
    reports and guarding behaviour
    most immediate problem to be solved.
    Subjective Cue: Modifiability is high since all the resources
    - “medyo nananakit pa siya are available. The salience is high since the
    konti, lalo na pag nagagalaw client takes the problem seriously.
    ung sugat tsaka kapag
    malamig ung panahon “

    Objective Cues:
    - Guarding behaviour
    - Pain Scale 8/10
    - Slowed movement
    - Facial mask of pain

    Measurements:
    BP- 80/60 PR- 92
    RR- 19
    T- 36.7
    3 Risk for infection related to open This problem is ranked last because it is not
    wound in lower abdomen secondary an actual problem but potential problem
    to T-tube and doesn’t need an immediate
    intervention.

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