CUES SUBJECTIVE:

DIAGNOSIS P: Alteration in Comfort (ACUTE PAIN) E: related to postoperative surgical incision (Gastrojejunostomy) S: As manifested by: Verbalization of the patient, Sumasakit yung tyan ko tuwing kumakain ako. Para syang hinihiwa na tinutusok, di ko ma-describe talaga, tapos yung sakit parang dumadaloy hanggang sa likod ko. Nasa 9 out of 10 yung sakit. As in sobra kasi talaga yung sakit, nawawala lang ng

RATIONALE External and internal factor aggravates the nerve endings causing production of prostaglandin, bradykinin,, histamine and progesterone to react on the specific region causing pain

GOAL SHORT TERM: After 30 minutes to 1 hour of nursing intervention, the patient will be able to reduce the level of pain felt as will be evidenced by a progressive improvement in his comfort status as will be evidenced by a reduce pain scale from 9/10 to 5/10.

INTERVENTIONS INDEPENDENT: Monitor signs vital

RATIONALE

EVALUATION SHORT TERM:

Sumasakit yung tyan ko tuwing kumakain ako. Para syang hinihiwa na tinutusok, di ko madescribe talaga, tapos yung sakit parang dumadaloy hanggang sa likod ko. Nasa 9 out of 10 yung sakit. As in sobra kasi talaga yung sakit, nawawala lang ng bahagya pag may pain reliever na pero may konting sakit pa din kahit nakainom na ako- as verbalized by the patient.

It serves as a baseline data to check if there are any deviations from his vital signs To assist etiology or contributing factors

After 30 minutes of nursing intervention, the patient was able to show improvement in condition as

Perform assessment

pain

Assist in diff. position like sitting or side-lying position Encourage diversional activities like watching television, listening to radio and socialization to others Provide comfort measures like touch and repositioning

It reduces muscle verbalized by the tension and fatigue patient: Medyo nawala yung sakit siguro nasa 4/10 na lang yung sakit

To distract attention

LONG TERM: REFERENCE: MedicalSurgical Nursing 3rd Ed. By Joyce Black pages 215-217 After 1 to 3 hours of nursing intervention the patient will be relieved from pain as will be evidenced by the absence of

GOAL MET To promote nonpharmacologic pain management

74

OBJECTIVES: Pain Scale of 9/10. Pain in the Abdominal area (+) Facial Grimace Restlessness Irritability

bahagya pag may pain reliever na pero may konting sakit pa din kahit nakainom na ako Pain Scale of 9/10. Pain in the Abdominal area Facial Grimace Restlessness Irritability

various signs showing manifestations of facial grimacing and restlessness.

Encourage use of relaxation techniques like deep breathing exercises DEPENDENT: Administer prescribed pain medications Nubain 5 mg IV q6 PRN and 2nd call, as ordered

To reduce tension LONG TERM:

After 2 hours of nursing intervention the patient still felt Unknown. pain scale of 4/10 Binds with opiate and still manifested receptors in the CNS, altering facial grimacing. perception of and emotional response to pain. GOAL NOT MET Depresses pain impulse transmission at the spinal cord level by interacting with opioid receptors, produces CNS depression Not completely understood, binds to opioid receptors and inhibit reuptake of norepinephrine and serotonin

Morphine Sulfate 0.02 10 mL/EC q12 x 5 doses, as ordered

Tramal 50 mg/IV PRN x breakthrough as rescue dose

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CUES

DIAGNOSIS

RATIONALE

GOAL

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

SUBJECTIVE: May paninilaw pa yung balat ko as verbalized by the patient.

P: Impaired Tissue Integrity E: Related to nutritional excess (Hyperbilirubinemia) secondary to pancreatic obstruction S: As manifested by: Damaged tissue Jaundice And verbalization of patient, May paninilaw pa yung balat ko

PANCREATIC MASS (Head: 5.35 x 4.16 cm) shown by ultrasound

SHORT TERM: After 3-5 hours of nursing interventions, the client will: Identify interventions appropriate for specific condition.

SHORT TERM: Identify underlying condition/ pathology involved in tissue injury. Suggests treatment options, desire/ ability to protect self, and potential for recurrence of tissue damage For comparative baseline After 3 hours of nursing interventions, the client was able to identified interventions appropriate for specific condition like early ambulation and That may be impacting tissue health. May be necessary to determine extent of impairment To facilitate healing 76 proper wound care. GOAL MET Assist with diagnostic procedures.

OBJECTIVES: Damaged tissue Jaundice

Obstruction of the Ampulla of Vater

Causing bile stasis and retrograde flow of the bile in the hepatic circulation

LONG TERM: After 1-2 days of nursing interventions, the client will: Demonstrate behavioral or lifestyle changes to promote healing

Assess skin/ tissues, bony prominences, pressure areas and wounds. Note poor hygiene/ health practices.

Increased Bilirubin levels present in the blood

Promote optimum nutrition

Yellowish discoloration of the skin and the eyes (Jaundice)

Display progressive improvement in his tissue condition.

with high-quality protein and sufficient calories, vitamins and mineral supplements. Encourage To limit adequate periods of metabolic rest and sleep demands, maximize energy available for healing, and meet comfort needs. Promote early mobility. Assist with/encourage position changes, active/passive and assistive exercises To promote circulation and prevent excessive tissue pressure

LONG TERM: After 2 days of nursing interventions, the client demonstrated behavioral or lifestyle changes to promote healing and was able to display progressive improvement in his tissue condition.

REFERENCE: Medical-Surgical Nursing 3rd Ed. By Joyce Black pages 1157-1158

GOAL MET

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CUES SUBJECTIVE: Hindi pa nga ako nadumi until now. Bale three days na yun as verbalized by the patient.

DIAGNOSIS P:Alteration Bowel in

RATIONALE Opiods use

GOAL SHORT TERM: After 4-5 hours of

INTERVENTIONS INDEPENDENT: Evaluate clients medication/drug regimen (opiods analgesics and NSAIDs) Note stool characteristics (color, odor, consistency, amount and

RATIONALE

EVALUATION

SHORT TERM: Which could exacerbate/cause of constipation After 5 hours of nursing intervention, Provides comparative baseline the patient had a normal number of abdominal sounds and abdomen was less rigid compared before. To improve consistency of stool and facilitate passage through colon To promote passage of soft stool 78 GOAL MET

Elimination Inhibition of peristalsis in the

(Constipation)

nursing intervention, the patient will have a normal number of abdominal sounds

E:related

to

small intestine and colon

pharmacological use (Opiod and analgesics Non-steroidal

anti-inflammatory drugs) OBJECTIVES: S: As manifested Hypoactive bowel sounds Distended abdomen (-) bowel movement for 3 days Verbalization of the patient, Hindi pa nga ako nadumi until now. Bale three days na yun Hypoactive by:

Increased electrolyte and water absorption Stools become hard

and abdomen will be less rigid compared before.

LONG TERM: After 10-12 hours

frequency) Instruct in/encourage a diet of balanced fiber and bulk (e.g. fruits, vegetables and whole grains) Promote adequate fluid

CONSTIPATION

of nursing intervention, the patient will establish a normal pattern of bowel functioning as

evidence by

intake, including

bowel sounds Distended abdomen (-) bowel movement for 3 days

REFERENCE:

bowel movement

high-fiber fruit juices Encourage activity/exercise within limits of individual ability Produces an osmotic effect in colon; resulting distention promotes peristalsis. Also decreases ammonia, probably as a result of bacterial degradation, which lowers the pH of colon contents To stimulate contractions of the intestines

LONG TERM: After 12 hours of nursing intervention, the patient established a normal pattern of bowel functioning as evidenced by bowel movement of at least one every day and verbalization of patient, Di na ako hirap makadumi ngayon. Regular na din yung pagdudumi ko. GOAL MET

of at least one Medical-Surgical every day and Nursing Vol. 1 5th verbalization of Ed. By Ignatavicius and patient, Workman p. 77 Nakakadumi na din ako ng regular.

DEPENDENT: Administer stool softeners (Lactulose 30 ml OD) as ordered

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CUES SUBJECTIVE: Yung sugat ko, feeling ko fresh pa din eh. as verbalized by the patient.

DIAGNOSIS P: Impaired Skin Integrity

RATIONALE Surgical intervention

GOAL SHORT TERM:

INTERVENTIONS INDEPENDENT: Keep the area clean and dry

RATIONALE

EVALUATION

SHORT TERM: Prevents infection and moistures harbours bacteria and pathogens After 1 hour of nursing interventions, the patient was able to understand the importance of proper wound care and able to demonstrate proper way of wound care to increase compliance GOAL MET to promote wound healing Splimting 80 and dressing.

(gastrojejunostomy, After 30 mins. to 1 E: Related to post operation surgery exploratory laparotomy). hour of nursing intervention the patient will be able to: S: As manifested by: Surgery involves cutting/ penetration Demonstrate of skin surface and Verbalization skin layers. proper way of wound care and proper dressing Injury or trauma on Understand the the skin. importance of proper wound care. Vasodilatation that hurriedly send nutrients in the body via the

Inspect the incision site every shift using REEDA (redness, edema, ecchymosis, discharge and approximation) Inform patient of the purpose of the self-care practice Encourage to increase protein intake

Frequent assessment can determine early signs and symptoms of infection.

OBJECTIVES: Simple dressing bilateral of the abdomen measuring 20 cm each Redness in the surrounding

of the patient, Yung sugat ko, feeling ko fresh pa din eh. Simple dressing bilateral of the abdomen

of the site

measuring 40 cm

bloodstream

LONG TERM:

Provide splinting pillow

provides support area. Minimizing discomfort and encouraging the patient to move and cough After 2 days of nursing intervention the patient was able to maintain the wound intact as evidenced by no LONG TERM:

After 3-4 days of Redness in the surrounding of the site Vasodilatation causes redness on the surrounding tissue on the injury site. nursing interventions the patient will be able to: Maintain the wound intact. REFERENCE: Shows signs of wound healing Principles of Medical-Surgical Vol.1 4 edition by Lemone and Burke p. 1078 No redness in the surrounding area.
th

Encourage early ambulation or mobilization

To promote circulation and reduces risk associated with immobility redness in the incision site but still To prevent infection To inhibit synthesis of bacterial cell wall GOAL NOT MET with signs of wound healing noted yet.

(dry and intact wound and initial scarring)

DEPENDENT: Carefully dress wounds with the physician Administer prophylactic antibiotic as prescribed

81

CUES

DIAGNOSIS

RATIONALE

GOAL

INTERVENTIONS

RATIONALE

EVALUATION

SUBJECTIVE: Hirap nga ako matulog eh. Maingay kasi yung mga bisita ng ibang

P: Disturbed Sleep Pattern

Time-limited disruption of sleep, amount and

SHORT TERM:

INDEPENDENT: Instruct to avoid heavy meals, alcohol, caffeine, or smoking before retiring Gastric digestion and stimulation

SHORT TERM:

After 2-3 hours of

After 2 hours of nursing interventions,

E: related to lack quality, affected by nursing of sleep privacy several environmental S: as evidenced factor as stated by Florence Nightingales Verbalization of the patient, Hirap nga Identify individually appropriate intervention to promote sleep. Environmental Theory Verbalize understanding of sleep disturbance. interventions, the client will:

from caffeine and the client was able to nicotine can disturb sleep pattern verbalized understanding of sleep disturbance and identified individually

pasyente dito. by: as verbalized by the patient.

Discourage pattern of daytime naps unless deemed necessary to meet sleep requirements if part of ones usual pattern

Napping can disrupt normal sleep pattern. However, the elderly do better with frequent naps during day to counter their shorter night time schedule

appropriate intervention to promote sleep.

OBJECTIVE: Restlessness Irritability

ako matulog eh. Maingay REFERENCE: kasi yung Theoretical Nursing p. 502 mga bisita ng Foundations of ibang pasyente dito

GOAL MET

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 Restlessness Irritability

LONG TERM:

Instruct to avoid strenuous

Over fatigue may cause insomnia

LONG TERM:

After 1-2days of nursing intervention the client will: Adjust lifestyle to accommodate chronobiological rhythm. Report improvement in sleep or rest patterns. Report increase sense of wellbeing and feeling rested.

activities before bedtime Encourage to increase daytime physical activities as indicated To reduce stress and promote sleep

After 2 days of nursing intervention the client have adjusted lifestyle to accommodate chronobiological rhythm, reported improvement in sleep or rest patterns.and report increased sense of well-being and feeling rested as the patient verbalized, Nakaka-adopt na ko ditto. Nakakatulog na din ako ng maayos.

GOAL MET

83