ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE Can provide reassurance that client safety precautions are constantly ongoing, alleviate clients anxiety, as well as provide information for formulating intraoperative care. Establishes rapport and psychological comfort with operative team. Provides for positive identification, reducing fear that wrong procedure may be done as well as minimizing risk for wrong procedure and site. Promotes relaxation.

EVALUATION

Subjective: Mild anxiety related Kinakabahan ako to upcoming surgery sa operasyon ko at hindi ako makatulog masyado. as verbalized by patient. Objective: V/S taken as follows: T: 37.1 P: 90 R: 18 Bp: 130/80 Restless Irritable Patient could not talk straight when asked about the surgery.

Anxiety is basically your bodys natural warning system telling you to go on alert when there is no actual cause for alarm. It is caused by a variety of biological, genetic, psychological and environmental factors. Those suffering from mild anxiety will usually only suffer from the physical and mental symptoms.

Independent: After 1-2 hours of Provide preoperative nursing education like interventions, the explaining the client should be procedure. able to Introduce client to experience a staff. reduction in fear Verbalize and and anxiety as document clients evidenced by: identifiers to surgery Verbalization of schedule; client feeling less identification band, anxious usual chart, marked site and sleep pattern, signed operative relaxed facial consent for surgical expression and procedure according to body facilitys protocol and movements. checklist. Provide a calm, restful environment.

After 1-2 hours of nursing intervention the client was able to: Experience a reduction in fear and anxiety as evidenced by verbalization of feeling less anxious usual sleep pattern, relaxed facial expression and body movements and stable vital signs.

ASSESSMENT Subjective: Kinakabahan ako sa operasyon ko at hindi ako makatulog masyado. as verbalized by patient. Objective: V/S taken as follows: T: 37.1 P: 90 R: 18 Bp: 130/80 Restless Irritable Patient could not talk straight when asked about the surgery.

NURSING DIAGNOSIS Mild anxiety related to upcoming surgery INFERENCE Anxiety is basically your bodys natural warning system telling you to go on alert when there is no actual cause for alarm. It is caused by a variety of biological, genetic, psychological and environmental factors. Those suffering from mild anxiety will usually only suffer from the physical and mental symptoms.

PLANNING
After 1-2 hours of nursing interventions, the

client should be able to experience a reduction in fear and anxiety as evidenced by: Verbalization of feeling less anxious usual sleep pattern, relaxed facial expression and body movements.

INTERVENTION Independent: Provide preoperative education like explaining the procedure.

RATIONALE

Can provide reassurance that client safety precautions are constantly ongoing, alleviate Introduce client to staff. clients anxiety, as well as Verbalize and document clients provide information for identifiers to surgery schedule; client formulating intraoperative care. identification band, chart, marked site Establishes rapport and and signed operative consent for psychological comfort with surgical procedure according to facilitys operative team. protocol and checklist. Provides for positive Provide a calm, restful environment. identification, reducing fear that wrong procedure may be done as well as minimizing risk for wrong procedure and site. Promotes relaxation.

EVALUATION After 1-2 hours of nursing intervention the client was able to: Experience a reduction in fear and anxiety as evidenced by verbalization of feeling less anxious usual sleep pattern, relaxed facial expression and body movements and stable vital signs.

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Madalas akong nangangati as verbalized by patient. Objective: Total bilirubin level 265.2 Scratching Redness in both arms and neck. jaundice V/S taken as follows: T: 37.1 P: 90 R: 18 Bp: 130/80

Risk for impaired skin integrity

Independent: Bilirubin is a After 30 minutes Instruct the client to byproduct of the of nursing cut his nails. breakdown of old interventions, the red blood cells. After client will be Instruct the client to around 120 days, relieved and take a bath your body removes know the regularly. old red blood cells different kinds of Instruct the client to from circulation and minimizing wear gloves (cloth) or breaks them down. itchiness. socks on his hands. Bilirubin is Use soft cotton linens, processed by liver calamine lotion, oil cells to produce bath and cool or moist bile, which is compress as indicated. removed via the bile Control ducts for disposal environmental through your urine Temperature. or stool. Cell Instruct client not to damage in your use tight clothing liver, or bile duct Collaborative: damage, can cause administer anti itching bilirubin to cream if prescribe accumulate and leak into the skin, causing jaundice. Accumulated bilirubin in the skin also causes itching. Bile duct obstruction can cause severe

To reduce risk of dermal injury when severe itchiness is present. to wash out the bilirubin in the skin that causes itchiness. To protect the skin from scratching. Reduces irritation, dryness of the skin and itching sensation. Coolness reduces itchiness. To prevent skin irritation To decrease itchiness

After 30 minutes of nursing interventions, the client verbalized minimal itchiness and demonstrated the different techniques to minimize itchiness.

ASSESSMENT Subjective: Madalas akong nangangati as verbalized by patient. Objective: Total bilirubin level 265.2 Scratching Redness in both arms and neck. jaundice V/S taken as follows: T: 37.1 P: 90 R: 18 Bp: 130/80

NURSING DIAGNOSIS
Risk for impaired skin integrity

INFERENCE Bilirubin is a byproduct of the breakdown of old red blood cells. After around 120 days, your body removes old red blood cells from circulation and breaks them down. Bilirubin is processed by liver cells to produce bile, which is removed via the bile ducts for disposal through your urine or stool. Cell damage in your liver, or bile duct damage, can cause bilirubin to accumulate and leak into the skin, causing jaundice. Accumulated bilirubin in the skin also causes itching. Bile duct obstruction can cause severe itching.

PLANNING
After 30 minutes of nursing interventions, the client will be relieved and know the different kinds of minimizing itchiness.

INTERVENTION Independent: Instruct the client to cut his nails.

RATIONALE

To reduce risk of dermal injury when severe itchiness Instruct the client to take a bath is present. regularly. to wash out the bilirubin in the Instruct the client to wear gloves (cloth) skin that causes itchiness. or socks on his hands. To protect the skin from Use soft cotton linens, calamine lotion, scratching. oil bath and cool or moist compress as Reduces irritation, dryness indicated. of the skin and itching Control environmental Temperature. sensation. Instruct client not to use tight clothing Coolness reduces Collaborative: itchiness. administer anti itching cream if To prevent skin irritation prescribe To decrease itchiness

EVALUATION
After 30 minutes of nursing interventions, the client verbalized minimal itchiness and demonstrated the different techniques to minimize itchiness.

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Prothrombin Time 19.8 Ceftriaxone

Risk for Bleeding

Independent: Liver is responsible After 30 minutes Instruct the client to for Prothrombin that of nursing be cautious especially is responsible for interventions, to sharp objects. And clotting factor. the client will instruct him to protect Ceftriaxone know the his head and be appears to alter Vit. precautionary cautious. K producing gut measures to bacteria, therefore prevent bleeding Administer Vit. K hypoprothrombinem and action of his IV q8 as prescribed. ic bleeding may drug. And tell the client occur. the effect of the drug to him.

To prevent him from cutting his self and to avoid bumping his head that may result from bleeding. Provides clotting and prevents bleeding

After 30 minutes of nursing interventions, the patient verbalized the understanding why he need to be cautious and the effect of administering Vit. K.

ASSESSMENT
Prothrombin Time 19.8 with Ceftriaxone NURSING DIAGNOSIS Risk for Bleeding

INFERENCE
Liver is responsible for Prothrombin that is responsible for clotting factor.

Ceftriaxone appears to alter Vit. K producing gut bacteria, therefore hypoprothrombinemic bleeding may occur.

PLANNING
After 30 minutes of nursing interventions, the client will know the precautionary measures to prevent bleeding and action of his drug.

INTERVENTION Independent: Instruct the client to be cautious especially to sharp objects. And instruct him to protect his head and be cautious.

RATIONALE To prevent him from cutting his self and to avoid bumping his head that may result from bleeding. Provides clotting and prevents bleeding

Administer Vit. K IV q8 as prescribed. And tell the client the effect of the drug to him.

EVALUATION
After 30 minutes of nursing interventions, the patient verbalized the understanding why he need to be cautious and the effect of administering Vit. K.