Nursing Management

Knowledge deficit

Assessment Subjective
Hindi ko alam kung bakit ako nagkaroon ng gantong sakit as verbalized by the patient

Diagnosis
Knowledge deficit r/t unfamiliarity of information resource

Planning
After 3 shifts of nursing intervention, the patient will gain knowledge about his condition

Intervention Independent: Discuss to the patient about his condition

Evaluation

Objective
Request for information Confuse

After 3 shifts of nursing intervention, the patient was able to gain knowledge Tell to the patient about his about the drugs shes condition taking up and the side effects Provide adequate environment conducive to learning Give time or session to avoid information overload

MILD ANXIETY

Assessment
Subjective

Diagnosis Planning Intervention

After 8 hours of nursing intervention the patient will appear relaxed and the level of anxiety is reduced to manageable level. Listening actively and focus on the patient discussed her personal feelings. Use appropriate touch with patient permission Instruct deep breathing exercise Speak in brief statements using simple words Give sedatives as ordered

Rationale
To establish trust and showing interest

Evaluation
After our shift the patient is relax and shows a good response by participating well in the activities

Mild Anxiety r/t to loss of Na mi-miss ko ang presence of the anak ko as verbalized family Objective Sleep disturbance Pale Looking

To demonstrate support

For relaxation

To avoid confusion and easy to understood To lessen excitement nervousness and irritation

ACUTE PAIN ASSESSMENT S: masakit yung tahi ko,kumikirot siya as verbalized by the patient. O: -pain scale of 8 out of 10 -facial grimace when moving -guarding behavior observed NURSING DIAGNOSIS Acute pain r/t stimulation of nerve endings secondary to surgical procedure SCIENTIFIC EXPLANATION Depending on the depth of injury, nerve endings either become exposed, resulting in pain and discomfort until wound closure are damaged leaving the innervated area insensate, with potential for permanent impairment of ability to sense, touch, pressure and pain. OBJECTIVES Short Term: After 8 hours of nursing interventions, patients pain will be decreased from 8 to 6 out of 10. Long Term: After two days of nursing intervention, the patient will demonstrate relaxation skills as indicated for individual situation AEB doing her ADL independently. INTERVENTION -Monitor v/s esp. BP -Perform a comprehensive assessment of pain to include location, characteristics, onset and duration, frequency, quality, intensity or severity of pain and precipitating factors -assess pts perception of pain -observe non-verbal cues -Provide comfort measures like repositioning RATIONALE -To have base line data -To know the precipitating factors of pain and to have necessary information about the case of the patient. EXPECTED OUTCOME Short term: Patients pain will be decrease from 8 to 6 out of 10.

-Pain is a subjective cue. -To confirm pts pain. -To provide a non pharmacologic al pain management such as administering pain relievers.

Long Term: Patients will demonstrate relaxation skills as indicated for individual situation AEB doing her ADL independently.

-Encourage adequate -To alleviate rest period pain -Encourage deep breathing exercise -To reduce pain by breathing exercise. -To divert the pain by listening to a music and watching t.v. -To treat underlying cause.

-Encourage diversional activities like listening to a music and watching TV -Administer analgesics as ordered

INEFFECTIVE TISSUE PERFUSION NURSING DIAGNOSIS Ineffective Tissue Perfusion r/t decreased hemoglobin concentration in the blood SCIENTIFIC EXPLANATION Due to the CS surgery, there is a massive blood loss. This will lead to the decrease in the concentration of hemoglobin in the blood and alteration in tissue perfusion. EXPECTED OUTCOME Short term: P atients will be able to demonstrate increased in perfusion AEB strong peripheral pulse and capillary refill of 1-2 secs.

ASSESSMENT S: O: Patient manifested: - Pallor - Capillary refill of 3 secs - Weak pulse - Hgb: 110g/dl

OBJECTIVES Short Term: After 8 hours of nursing intervention, patients will demonstrate increased in perfusion AEB strong peripheral pulse and capillary refill of 1-2 secs. Long Term: After one day of nurse patient interaction, Patient will be able to understand the condition and treatment regimen to improve tissue perfusion.

INTERVENTION -Monitor v/s esp. PR -Assess patients condition especially signs and symptoms of disease such as pulse rate and capillary refill -Review laboratory studies -Identify changes related to systemic and/or peripheral alterations in circulation -Encourage early ambulation -Encourage quiet, restful atmosphere

RATIONALE -To have base line data -To have base line data

-To provide comparison -To assess the extent of involvement Long Term: Patients will verbalize understanding of the condition and treatment regimen to improve tissue perfusion.

-To promote venous return -To conserve energy and lowers tissue oxygen demands.

-Provide comfort measures such as repositioning -Monitor signs of bleeding -Transfuse blood as ordered

-To help patient to relax -To prevent further injury -To replace blood loss

IMPAIRED SKIN INTEGRITY

ASSESSMENT S: O: Patient manifest: - Presence of surgical incision in the abdomen - Intact and dry dressing - (+) pain

NURSING SCIENTIFIC DIAGNOSIS EXPLANATION Impaired skin Due to the incision integrity r/t done during abdominal surgery, there will incision 2 be disruption of surgery the skin surface that will lead to the impairment of the skin integrity.

OBJECTIVES Short Term: After 4 hours of nursing interventions, patients will be able to understand on how to promote wound healing and prevent further complications. Long Term: After 2 days of NPI, Patient will be able to participate in prevention measures and treatment program such as eating nutritious foods rich in protein and Vit. C such as citrus fruits.

INTERVENTION Assess pts condition

RATIONALE -

Assess skin noted color, turgor, sensation, and signs of infection Described and measured wounds and observed changes. -

Determine the depth of damage Keep the area clean and dry Remove wet linens promptly. Change dressing everyday as ordered Encourage early ambulation Instruct to eat nutritious food rich in protein and Vit. C. Review

EXPECTED OUTCOME Short term: To have Patient will be base line able to data verbalize To know for understanding the presence on how to of infection promote wound healing and Establishes prevent comparative further complications baseline providing opportunity Long Term: Patient will for timely intervention. be able to participate in prevention To assess measures and the injury treatment To promote program such as eating healing nutritious foods rich in To prevent protein and skin Vit. C. such as breakdown citrus fruits. To prevent infection

To promote circulation To aid in healing

To promote

ACTIVITY INTOLERANCE ASSESSMENT S: hindi ako gaano makagalaw, nanghihina pa kasi ako saka nagaalala ako sa naopera ko as verbalized by Patient. O: The group observed that Patient is: NURSING DIAGNOSIS Activity intolerance related to generalized weakness and presence of pain secondary to surgical procedure SCIENTIFIC EXPLANATION Inadequate oxygen in the circulation can develop weakness in our muscles. Muscles need oxygen to move and to do its function. If the patient cannot tolerate any activities because of the low OBJECTIVES Short term: After 8 hours of nursing intervention, Patient will report activity intolerance with enhanced energy, and she will participate willingly in desired INTERVENTION monitor the vital signs provide health teaching to Patient regarding the organization and time management technique to prevent while on RATIONALE to obtain baseline data to provide adequate knowledge to Patient. EXPECTED OUTCOME Short term: Patient will report activity intolerance with enhanced energy, and she will participate willingly in desired activities.

irritable uncomfortable worried immobility weakness

oxygenation caused by the ventilationperfusion imbalance caused by the pathological minimized lung expansion.

activities. Long term: After one day of NPI, Patient will identify techniques to enhance activity tolerance AEB doing her ADL independently. -

activity adjust activities, reduce intensity level or discontinue activities that cause undesired physiologic changes suggest use of relaxation techniques assist Patient to learn and demonstrate appropriate safety measures to prevent overexertion Long term: Patient will identify techniques to enhance activity tolerance AEB doing her ADL independently.

To enhance sense of well-being To prevent or protect Patient from injuries

RISK FOR INFECTION ASSESSMENT S: O: Patient may manifest: - Increased environmental exposure, tissue destruction - Inadequate primary defenses due to abdominal incision and trauma brought about by NURSING SCIENTIFIC OBJECTIVES DIAGNOSIS EXPLANATION Risk for A surgical Short Term: infection incision is prone After two hours related to to pathogenic of nursing inadequate bacteria that will interventions, primary cause infection to Patient will be defenses due to the broken skin. able to identify tissue trauma The bacteria will interventions to caused by be able to enter prevent the risk surgery. the incision and for infection like may infect the hand washing. wound. Long Term: After one day of nursing interventions, INTERVENTION Monitor v/s esp. PR , RR and temperature Assess patients condition Assess the surgical incision for signs of infection Stress proper hand washing when the patient is going to have EXPECTED OUTCOME - To have Short term: base line data, Patient will fever maybe identify secondary to interventions infection to prevent the risk for - To have infection like base line hand washing data - To know for after 2 hrs of the presence nursing of infection interventions. - To prevent cross contaminati Long Term: on RATIONALE

surgery - (+) pain

Patient will demonstrate techniques to decrease risk for infection such as frequent changing of dressing.

in contact to the wound Encourage early ambulation, deep breathing, coughing exercises, and position changes Changed dressing as ordered Administer antibiotics as ordered. - To mobilize respiratory secretions

To prevent infection For prophylaxis

Patient will be able to demonstrate techniques to decrease risk for infection such as frequent changing of dressing.