I.

II. B. PLANNING (NURSING CARE PLANS)

Problem # 1: ACUTE PAIN Assessm ent S: O O: The patient may manifest: > Pain on the gastric area >pain scale of 8/10 >(+) facial grimaces >(+) guarded behavior >restless ness >cold clammy skin >limited movemen t Nursing Diagnosis Acute pain Scientific Explanation acute pain starts with the stimulation of one or more of the many special sense receptors, called nociceptors, in the skin. These receptors receive information about tissue trauma or other events that can cause body damage. Two types of nerve fibers carry this information from the nociceptors to the spinal cord: Adelta fibers, which transmit information quickly and appear to be responsible for the acute sense of pain; and C-type fibers, which transmit impulses Objectives Short term: After 4 hours of nursing interventions, the patient will be able to verbalize a reduction of pain AEB decreased pain scale of 8/10 to 4/10, reduction of facial grimaces, guarding behavior ()cold clammy skin, and () restlessness. Intervention >Establish rapport. Rationale >To facilitate health care intervention and promote participation and compliance to treatment regimen. >To get baseline data and to note progress of patients condition. >To assist the client to explore methods of alleviation or control of pain. Listening to the patient respectfully and implying an alliance against pain help reduce anxiety. Expected outcome Short term: The patient shall have verbalized a reduction of pain AEB decreased pain scale of 6/10 to 4/10, reduction of facial grimaces, guarding behavior ()cold clammy skin, and () restlessness. Long term: The patient shall have verbalized a total relief of pain AEB absence of pain, ()

>Assess, monitor and record vital signs. >Encourage verbalization of feelings about the pain.

Long term: After 2 weeks of

>selffocusing >narrowe d focus

more slowly and may cause the nagging sense of pain. At the spinal cord, messages from nociceptors may be modulated by other spinal nerves that enhance or, more frequently, diminish the intensity of the pain stimulus. The impulse then travels to several parts of the brain. Some brain areas determine where the pain is and what is causing it, while other areas integrate the sensory information with the total state of the organism and produce the emotional sensation called pain.

nursing interventions, the patient will be able to verbalize a total relief of pain AEB absence of pain, () facial grimaces, () guarding behavior, can totally move without experiencing pain, () cold clammy skin and () restlessness.

>Note nonverbal pain cues.

>Non verbal cues may be both physiologic and psychological and may be used in conjunction with verbal cues to evaluate extent or severity of the problem. >Helpful in establishing diagnosis and treatment needs. >Careful analysis of pain characteristics aids in the differential diagnosis of pain. Systemic analysis prevents hasty and possibly inaccurate conclusions

facial grimaces, () guarding behavior, can totally move without experiencing pain, () cold clammy skin and () restlessness.

>Review factors.

>Analyze and document pain characteristics: precipitators, quality, region and radiation, severity, and time (frequency and duration).

about the quality or probable cause of pain. Standardized pain rating improves accuracy. >Work with the patient to identify the most effective ways to control pain. >Involving the patient in paincontrol strategies promotes a sense of mastery that reduces fears of helplessness or loss of control. >Patient may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing

>Eliminate additional stressors or source of discomfort like environmental factors whenever possible.

>Provide rest

periods to facilitate comfort, sleep, and relaxation.

her. >Feeling wellrested increases tolerance of pain and the ability to cope with it. A quiet and clean environment is a measure geared towards facilitating rest. >Hot, moist compress has a penetrating effect. The warmth rushes blood to the surrounding area to promote healing. A cold compress may reduce total edema and promote numbing, thereby promoting comfort. >These

>Provide comfort measures such as hot or cold compress.

>Explore various behavioral pain-control

strategies including relaxation techniques and distraction techniques.

>Encourage to have adequate fluid intake and of nutritious foods rich in vitamin C, iron and protein. >Administer and document analgesics as ordered.

techniques reduce muscle tension, enhance rest, and promote a sense of wellbeing by stimulating the relaxation response. Distraction is helpful for brief episodes of pain, but may increase pain perception and fatigue after the distracting stimulus is removed. >Promotes faster wound healing.

>Nonnarcotic analgesics work peripherally, inhibiting

formation of prostaglandins and bradykinins. These are used to maintain acceptable level of pain.

PROBLEM #2: HYPERTHERMIA ASSESSMENT NURSING DIAGNOSIS Hyperthermi a SCIENTIFIC EXPLAINATIO N When the causative agent enters the body and invades the respiratory system, the inflammatory process is triggered releasing platelets, WBC, RBC, which produces exudates of fibrin, which enhances the spread of microorganism , causing infection. In response to infection, the individual WBC release pyrogens. OBJECTIVES INTERVENTIO NS 1. Establish Rapport RATIONALE EXPECTED OUTCOME Short term: After 4 of NI, the pts temperature shall drop 2. To establish baseline data of the pts from 38.4 C to 37 C.

S>

O> the patient manifested >Flushed skin >skin warm to touch >with body temperature of 38.4C -The patient may manifest >dehydration >Irritability

Short term: After 4 of NI, the pts temperature will drop from 38.4 C to 37 C

1. To gain trust and have a nurse patient relationship

2. Monitor VS q 4.

3. Provide TSB as a measure. Long term: After 2-3 days of NI, the patient will be free from hyperthermia. 4. Instruct SO to provide with loose clothing. 4. To release heat and to provide comfort 3. To lower pts temperature Long term: After 2-3 days of NI, the patient shall be free from hyperthermia.

5. Assess skin

These pyrogens affect the body temperatureregulating mechanism in the hypothalamus of the brain. As a consequence, heat production and conservation increase, a body temperature increases. Fever promotes activities of the immune system, such as phagocytosis, inhibits the growth of some microorganism .

temperature and color. 5. Warm, dry, flushed skin may indicate a fever.

6. Monitor WBC count. 6.Leucocytes indicate an inflammatory and infectious process presence. 7. Encourage fluid intake orally or intravenously as ordered. 8. Measure intake and 8. Determine 7. Replaces fluid lost by insensible loss and perspiration.

output.

fluid balance and need to increase fluid intake.

Problem #3 ACTIVITY INTOLERANCE r/t generalize weakness Assessme nt Nursing Diagnosis Scientific Explanation Objectives Intervention Rationale Expected outcome

S: O: Patient may manifest >limited movement >report of pain and discomfort upon movement >inability to perform self-care activities >weaknes s >fatigue

Activity Intolerance r/t generalize weakness

There is a limitation in independent, purposeful physical movement of the body or of one or more extremities due to weakness that the patient experiences brought about by decreased oxygen delivered to body tissues. This limits the patients mobility and is often exacerbated by movement leading to activity intolerance.

Short-term: After 4 hours of nursing interventions, the patient will be able to use identified techniques to enhance activity tolerance AEB decreased limited movement, and can perform selfcare activities with assistance.

>Establish rapport.

>To facilitate health care intervention and promote participation and compliance to treatment regimen. >To get baseline data and to note progress of patients condition. >To assess factors affecting current situation. >Pain limits mobility and is often exacerbated by movement. > To conserve energy and promote

>Assess, monitor and record vital signs.

The patient shall have identified techniques to enhance activity tolerance AEB decreased limited movement, and can perform self-care activities with assistance. Long-term: the patient shall have reported a measurabl e increase in activity tolerance AEB absence of limited movement, and can perform self-care

>Identify factors that could affect desired level of activity.

Long-term: After 2 weeks of nursing interventions, the patient will be able to report a measurable increase in activity tolerance AEB

>Before activity, observe for and if possible treat pain.

> Instruct client in unfamiliar activities

absence of limited movement, and can perform selfcare activities without assistance.

and in alternative ways of doing familiar activities. > Assist client/SO(s) with planning for changes that may become necessary. > Identify and discuss symptoms for which client needs to seek medical assistance/evaluation . > Refer to appropriate sources for assistance and/or equipments as needed. >Encourage to perform passive ROM exercises at least 2x a day.

safety. >To promote wellness.

activities without assistance.

> To provide for timely intervention.

> To sustain activity level.

>Inactivity rapidly contributed to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation

of movement. >To reduce fatigue. >Provide adequate rest periods. >Provide ample time to perform mobilityrelated tasks. >Encourage to participate in selfcare activities. >Limits fatigue, maximizing participation. >Enhances self-concept and sense of independence.

Problem# 4: RISK FOR INFECTION Assessem ent Nursing Diagnosi s Scientific Explanati on Objectives Intervention Rationale Evaluation

S:O O: Patient manifested : >(+) cold clammy skin > c low hemoglobi n and hematocrit count >poor personal hygiene Patient may manifest: >increased temperatur e >chills

Risk for spread of infection r/t inadequat e secondary defenses as evidenced by low hematocri t and hemoglobi n count.

Due to low count of hematocrit and hemoglobi n and poor hygiene, risk for infection is greater. The skin, which is the bodys first line of defense, wherein whose natural defense mechanis ms are inadequat e to protect the patient from exposures that occur throughout the course of living. Risk for

Short-term: After 4 hours of nursing interventions, the patient will be able to verbalize understanding of individual risk factors to prevent/reduce risk of infection AEB patient has demonstrated techniques/lifest yle changes to prevent/reduce risk of infection by improving personal hygiene, ()cold clammy skin Long-term: After 2 weeks of nursing interventions, the patient will be free from signs/symptoms of infection AEB maintenance of good personal

>Establish rapport.

>To facilitate health care intervention and promote participation and compliance to treatment regimen. >To get baseline data and to note progress of patients condition. >To assess causative/contributi ng factors. > A first-line defense against nosocomial infections.

>Assess, monitor and record vital signs. >Note risk factors for occurrence of infection. >Stress proper handwashing techniques by all caregivers between therapies/clients. > Monitor visitors/caregiver s. >Administer and monitor medication regimen and note the clients

Short-term: the patient shall have verbalized understanding of individual risk factors to prevent/reduce risk of infection AEB patient has demonstrated techniques/lifest yle changes to prevent/reduce risk of infection by improving personal hygiene, ()cold clammy skin

>To prevent exposure of the client. > To determine the effectiveness of therapy/presence of

Long-term: the patient shall have been free from signs/symptoms of infection AEB maintenance of good personal hygiene, () cold clammy skin

infection may occur when an organism invades a susceptibl e host.

hygiene, () cold clammy skin

response. > Administer prophylactic antibiotic. > Review individual nutritional needs and need for rest. >Instruct client/SO(s) in techniques to prevent the spread/occurrenc e of infection.

side-effects.

>To reduce/correct existing factors. >To promote wellness.

>To promote wellness.

Problem #5 RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS

CUES S: O: The patient manifested: lack of appetit e inadeq uate intake of nutriti ous food >patients SO verbalization of a decrease in patients body weight r appear s pale and weak Patient may manifest: poo

NURSING DIAGNOSIS Risk for imbalanced nutrition: less than body requirement s

SCIENTIFIC EXPLANATION loss of appetite may also develop due to anemia, the demand for energy . Increase in the number of immature and ineffective lymphocytes will utilize the nutrients intended for the bodys needs, thus causing weight loss. Condition presented put the patient to the problem of risk for altered nutrition: less than body requirement related to anorexia.

DESIRED OUTCOME Short term: After 4 hrs of nursing interventions, the patient will demonstrate an increase in appetite AEB increased fluid and food intake. Long term: After 1 week of nursing interventions, the client will maintain optimal nutritious status AEB stabilized weight and increased fluid and food intake.

NURSING INTERVENTIONS Note patients daily total intake.

RATIONALE Reveal changes that should be made in patients dietary intake. Bowel sound may be diminished/ absent if the infection process is severe/ prolonged. Abdominal distention may occur as a result of air swallowing or reflect the influence of bacterial toxins on the GI tract. These measures may enhance intake even though appetite may be slow to return.

Auscultate bowel sounds. Observe/palpate for abnormalities distension.

EXPECTED OUTCOME Short term: the patient shall have demonstrated an increase in appetite AEB increased fluid and food intake. Long term: the client shall have maintained optimal nutritious status AEB stabilized weight and increased fluid and food intake.

Other than encouraging milk feeding, Provide small, frequent juices that are appealing to the patient. Evaluate general

r mu scl e ton e cap illar y fra gilit y

nutritional state, obtain baseline weight.

Presence of chronic condition or financial limitation can contribute to malnutrition, lowered resistance to infection, and/or delayed response to therapy. To enhance intake by decreasing negative stimuli. May have a negative effect on appetite. Rest decreases metabolic needs. There are increased metabolic needs secondary to fever and infectious process.

Promote pleasant, relaxing environment. Prevent/minimiz e unpleasant odors/sights. Limit activities.

Provide oral care

before drinking and after coughing.

Sputum can be foul tasting and decrease appetite.

Problem #6 : DISTURBED SLEEP PATTERN CUES NURSING DIAGNOSIS SCIENTIFIC EXPLANATION DESIRED OUTCOME NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S: O: pt. may manifest: >verbal complaints of difficulty falling asleep >restlessnes s >altered facial _expression (fatigued appearance) >verbal complaints of not feeling rested >irritability >dozing >yawning >difficulty in arousal >change in activity level

Disturbed sleep pattern r/t environmen tal factors e.g. noise AEB verbalizatio n of difficulty of sleeping.

Sleep is required to provide energy for physical and mental activities. The sleep-wake cycle is complex, consisting of different stages of consciousness. Disruption in the individuals usual diurnal pattern of sleep and wakefulness may be temporary or chronic. Such disruptions may result in both subjective distress and apparent impairment in functional activities. Sleep patterns can be affected by environment,

SHORT TERM: After 3 hours of NI, patient will able to have adequate rest AEB verbalization of feeling rested, and improvement in sleep pattern. LONG TERM: After 3 days of NI, patient will achieve optimal amounts of sleep AEB rested appearance, verbalization of feeling rested, and improvement in sleep pattern

Establish rapport.

To facilitate health care intervention and promote participation and compliance to treatment regimen. To have a comparative/bas eline data to note progress of condition. To assess sleeping pattern and problems encountered by the patient

Assess, monitor vital signs.

SHORT TERM: The patient shall have had adequate rest AEB verbalization of feeling rested, and improvement in sleep pattern. LONG TERM: The patient Shall have achieved optimal amounts of sleep AEB rested appearance, verbalization of feeling rested, and improvement in sleep pattern

Assess past patterns of sleep in normal environment: amount, bedtime rituals, depth, length, positions, aids and interfering agents. Identify factors that may facilitate or interfere with normal patterns. Instruct patients to follow a

To identify appropriate nursing interventions To facilitate sleeping patterns

especially in hospital critical care units.

consistent daily schedule for retiring and arising as possible. Instruct to avoid heavy meals, alcohol, caffeine, or smoking before retiring. Instruct to avoid large fluid intake before bedtime. This can alter in promoting sleep

To avoid in between waking at night and promote rest and sleep