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JAUNDICE CASE STUDY NURSING CARE PLAN

Assessment Subjective: Hindi ako makaihi kahit anung pilit ko, as verbalized by the client. Diagnosis Urinary retention related to reduced bladder muscles contractility Scientific knowledge administration of anicholinergic drug (atrophine sulfate) Planning Short term goal: Within 2-3 hours of nursing intervention the client will: inhibition of acetyl choline production Verbalize understanding causative factors and appropriate interventions. demonstrate techniques and behavior to alleviate retention Long-term goal: Intervention INDEPENDENT: Assist to upright position on bedpan Provide privacy Use ice techniques, spirits of wintergreen, stroking inner thigh, running water or warm water over perineum. DEPENDENT: Catheterize with intermittent or indwelling catheter To provide functional position of voiding. Stimulate reflex arc Resolve acute urinary retention Rationale Evaluation Goal met -after 2-3 hours of nursing intervention the client: Verbalized understanding causative factors and appropriate interventions. demonstrate techniques and behavior to alleviate retention Goalmet - after 2 days of nursing intervention the client voided in sufficient amounts with no palpable bladder distention

stimulation of SNS

Objective: Post-operative Urine-output= 0 With palpable bladder distention

decreased bladder contractility

Reference: Nurses pocket guide, pp. 754

signs and symptoms Within 2 days of nursing (urinary retention) intervention the (Medical-Surgical client will void in Nursing 10th edition sufficient amounts - Brunner & with no palpable Suddarth) bladder distention.

ASSESSMENT Subjective: nahihirapan ako kumilos dahil sa aking tahi as verbalized b the client.

DIAGNOSIS

Scientific knowledge Surgical incision of the abdominal wall Actual tissue damage peripheral receptors initiate unpleasant sensations modulation in the dorsal horn of the spinal cord activation in the cerebral cortex pain sensation Activity intolerance

PLANNING Short term goal: -within 5-8 hours of nursing intervention the client will: use identified techniques to enhance activity tolerance Willingly participate in necessary/ desired activities. Report measurable increase n activity tolerance. Demonstrate a decrease in physiological signs of intolerance.

INTERVENTION

RATIONALE

EVALUATION Goal met

Objective: Tired facial expression Uncomfortable Worried In pain (7/10 pain scale) T- 36.4 C P- 84 bpm R-22breaths/min

Activity intolerance related to surgery as manifested by decreased mobility.

Adjust activities Increase exercise levels gradually.

Plan care to carefully balance rest periods with activities. Provide positive atmosphere Promote comfort measures Encourage client to maintain positive attitude.

To prevent overexertion. Nurses pocket guide 11th edition, pp. 72 To conserve energy. Nurses pocket guide 11th edition, pp. 72 To reduce fatigue Nurses pocket guide 11th edition, pp. 72 Helps minimize frustration and rechannel energy Nurses pocket guide 11th edition, pp. 72 To enhance sense of well-being

-after 5-8 hours of nursing intervention the client: used identified techniques that enhance activity tolerance Participated willingly in desired activities. Reported measurable increased in activity tolerance. Demonstrated decreased in physiological signs of intolerance. Goal met After 2 days of nursing intervention, the client can tolerate her activities

Long-term goal: -within 2 days of nursing intervention the client will tolerate her activities.

Assessment Subjective: ang sakit ng tahi ko, as verbalized by the client.

Diagnosis Acute pain related to actual tissue damage as manifested by Pain scale of 7 over 10.

Scientific knowledge

Planning Short term goal:

Intervention INDEPENDENT: Instruct client to report any improvement/aggr avation in pain experience Provide comfort measures(back rub, change of position) Encourage and assist client to do deep breathing exercises.

Rationale

Evaluation

Surgical incision of the abdominal wall

Objective: Facial grimace Guarding behavior Irritability Withdrawn behavior T- 36.4 C P- 84 bpm R-22breaths/min

Actual tissue damage

Within 2-3hour of nursing intervention the client will: verbalize method that provide relief demonstrate relaxation skills and divertional activities as indicated for her situation follow prescribe pharmacological regimen.

Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client. Very few people lie about pain. (Medical-Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 443) To promote nonpharmacological pain management (nurses pocket guide, 11thed. By Doenges Marilynn, p.501 Deep breathing for relaxation is easy to learn and contributes to pain relief and/or reduction by reducing muscle tension and anxiety (MedicalSurgical, 7thed. By black, joyce M. &janeHokansan hawks; p.479) To maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal. (nurses pocket guide, 11th ed. By Doenges Marilynn, p.502)

Goalmet After 2-3hour of nursing intervention the client: verbalized method that provide relief (the patient stated methods that provide relief like changing position) demonstrated relaxation skills and divertional activities as indicated for her situation (the client can demonstrate deep breathing exercise) Followed prescribe pharmacological regimen. (the patient is able to

peripheral receptors initiate unpleasant sensations

modulation in the dorsal horn of the spinal cord

Long-term goal: activation in the cerebral cortex -Within 8 hours of nursing intervention the client will report pain is relieved or controlled.

pain sensation

( acute pain) DEPENDENT: (Medical-Surgical Nursing 10th edition - Brunner & Suddarth) Administer analgesic as indicated to maximal dosage as needed. Reference: Nurses pocket guide, pp. 754

take analgesic in right time without refusal.)

ASSESSMENT

DIAGNOSIS

SCIENTIFIC KNOWLEDGE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Objective:

Impaired tissue integrity related Incision at RUQ to surgical T-tube drain incision with slightly soaked.

Surgical incision of the abdominal wall

Short term goal: -within 4-5 hours of nursing intervention, the client will be able to:

Check the T-tube drain; make sure that they are free flowing. Observe color and character of the drainage. Place patient in low or semi-fowlers position. change dressings as often as necessary. Administer antibiotics as ordered.

Incision site drains are used to remove any Goal Met accumulated fluid and bile. Correct positioning After 4-5 hours of prevents back up of the bile nursing intervention, the in the operative area. client : Initially, may contain blood and blood-stained fluid, normally changing to greenish brown (bile color) after the first several hours. Facilitates drainage of bile. Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation. -Necessary for treatment or prophylaxis for abscess or infection

removal of the bile bladder

application of T-tube

Demonstrates understanding of plan to heal skin Describes measures to protect and heal the skin and to care for any skin lesion

Demonstrates understanding of plan to heal skin Describes measures to protect and heal the skin and to care for any skin lesion

Impaired skin integrity

Long-term goal: Within 3 weeks of nursing intervention the client will regains integrity of skin surface.

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