COMPETENCY APPRAISAL WORKSHEET GUIDE.

Submitted by: Shanna Mariz I. Janolo

Submitted to: Mr. Gaudymer Lopez RN.,MAN.

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Fill the table with appropriate nursing interventions: patient Noemi undergoing adrenalectomy. Five interventions each phase. INTRAOPERATIVE INTERVENTIONS RATIONALE 1. The patient 1. So, the patient should be should be informed about aware on the IV infusions , contraptions hymodynamic given. monitoring techniques, nasogastric suctioning. 2. Monitor vital 2. For baseline signs. data. 3. Protect client 3. It will cause from exposure further to infectious complications microorganism to the client. 4. Employ 4. As a universal careful hand precautios. washing technique before contact with the patient. 5. To prevent 5. Protect client client from from falls and injury accident. POSTOPERATIVE INTERVENTIONS RATIONALE 1. Intake and 1. To maintain output must be baseline data. measured accurately and must measure frequently. 2. Be alert in any 2. It can cause signs of adrenal client further insufficiency. complications.

PREOPERATIVE INTERVENTIONS RATIONALE 1. Explain the 1. To inform the client about client about the procedure. procedure. 2. To prevent 2. Assess BP hypotension. and fluid volume frequently. 3. Provide a nutritional support in promoting physical stamina. 3. To withstand the rigors of surgery and improve wound healing postoperativel y.

3. Encourage client to eat high in protein and carbohydrate. 4. Avoid client prolonged fasting.

3. For client nutrition.

4. Fasting can precipitate hypoglycemic episodes. 5. Client should have a sufficient rest periods along with comfort measures.

4. Instruct client postoperative coughing, deep breathing and turning.

4. It gives the patient confidence and promotes complications

5. Anticipate stressful situations for the patient and prevent.

5. Explain that diet high in protein and and vitamins are helpful

5. Since glucocorticoid exceeds produces a state of catabolism.

6. Diff. nursing responsibilities of the patient undergoing radioactive therapy. Keep the skin dry. Should remove ink marks. Avoid using powders, lotion, creams, alcohol, and deodorant. Wear loose fitting clothes. Protect skin from direct sunlight, chlorine and extreme temp.

7. Nursing diagnosis and nursing interventions for patient Shane (dse. Graves disease.)

A. Less than body requirements r/t accelerated metabolic rate. Provide client with well balanced, high calorie diet. Encourage client to eat foods that are nutritious and contain ample amounts of protein, carbohydrates, fats, and minerals. Clients should weight daily and weight losses of more than 4.4lb should be reported B. Activity intolerance r/t exhaustion secondary to accelerated metabolic rate. Provide client with environment that is restful. Promote rest. Prevent them from disturbing.

C. Hyperthermia r/t increase metabolic rate. Provide client with cool environment. Use only a lightweight sheet for the top cover and give them light loose pajamas. If the client is diaphoretic, may need to change the bed sheets and clothes frequently.

8. Signs of escalating anxiety for shielas behavior. Increasingly withdrawn Agitated Irritable Management: CATEGORIZE. Distraction. Fighting back Isolation Attempts to feel better Help-seeking

9. Diagnosis and Interventions for shiela who has expects of having schizophrenia. 3 DIAGNOSES: Disturbed thought process r/t presence of persecutory delusions. Self-care deficit r/t poor personal hygiene. Ineffective coping r/t fear.

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INTERVENTIONS Monitor for physical discomfort such as pain and physical illness. Remove clients from or avoid situation know to cause agitation. Decrease stimulants such as caffeine, bright lights and load noise and music. Avoid criticism and do not argue. Avoid display of anger, discouragement, or frustrations when interacting with them.

RATIONALE 1. Close observation to client will prevent it from self harm. 2. To prevent client for further injury. 3. It may help the client to relief from stress. 4. Client can think that may cause them hurt themselves. 5. So, they cannot disappointment them.

REFERENCE: Stuart, Gail W. et al, 2005, Principles and Practice of Psychiatric Nursing 8th edition, pp. 414-415 Black, Joyce M., et al, 1993, Saunders Company, Luckmann and Sorensens Medical- Surgical Nursing A Psychophysiologic Approach, 4th edition pp.1818-1847

Shanna Mariz I. Janolo N4E NURSING CARE PLAN FOR RISK FOR INJURY ASSESSMENT DIAGNOSIS PLANNING Subjective: Risk for injury After hours of nursing intervention client will Increased muscle related to increased muscle be able to: weakness. weakness. Difficulty Short term: climbing the Free from stairs to another incidence of Easy fatigability fall, patients safety will be Objective: ensured. Protruding abdomen and Long term: buttocks Demonstrate Round face behaviors, Presence of lifestyle edema changes to Obvious facial reduce risk hair factors and Numerous protect self bruises in the from injury skin BP: 160/90 Ca: 4.3 mEq/L

INTERVENTION INDEPENDENT: Assess the person for factors known to increase fall risk such as history of falls, mental status changes and sensory deficits Assess patients environment for factors known to increase fall risk such as unfamiliar setting and inadequate lighting

RATIONALE

Evidence indicates that a person who has sustained Short term: one or more Free from falls in the incidence of past year is fall, patients more likely to safety will be fall again ensured. Long term: Patients who Demonstrate are not behaviors, familiar with lifestyle the placement changes to of furniture reduce risk and factors and equipment in protect self the room are from injury more likely to experience a fall.

EVALUATION After hours of nursing intervention client was able to:

Place items used by the patient within

Stretching to get items from bedside

easy reach

Use side rails on beds as needed.

Encourage the patient to participate in a program of regular exercise

tables that are out of reach can disrupt the patients balance and contribute to falls Patients who are disoriented or confused have been known to climb over siderails and fall Evidence suggests that people who engage in regular exercise and activity will strengthen muscles

DEPENDENT: Encourage the patient to wear shoes or slippers with nonskid soles

Nonskid footwear provides sure footing for the patient

when ambulating

Orient the patient to the layout of the room.

Provide the patient with a chair that has a firm seat and arms on both sides

with diminished foot and toe lift when walking The more familiar the patient is with the layout of the room, the less likely the patient is to trip over furniture This chair style is easier to get out of especially when the patient experiences weakness and impaired balance when transferring from bed to chair Incorrect use or improper maintenance of canes,

Educate the patient and family caregivers

about the correct use and maintenance of mobility assisted devices COLLABORATIVE: Refer the person for diagnostic musculoskeleta l evaluation

walkers and wheelchairs can increase the risk for falls

Collaborate with other health care team members to evaluate the patients medications that contribute to falling

Physical therapy evaluation can identify problems with balance and gait that can increase a persons fall risk A review of the patients medication by the prescribing health care provider and the pharmacist can identify side effects and drug interaction

Refer the family to community resources for assistance in making home safety modifications

Many community service organizations provide financial assistance to help older alults make safety improvement s