NCP Gouty Arthritis
NCP Gouty Arthritis
NCP Gouty Arthritis
NURSING MANAGEMENT
PRE-OPERATIVE NURSING CARE PLANS
Problem # 1: Acute Pain
Assessment Nursing Diagnosis Scientific explanation Objectives Nursing Interventions Rationale Expected Outcome
S= O=Patient manifested:
ability
The presence of a tumor creates an obstruction in the colon and because of this mechanical obstruction or fecal impaction, there is an impairment of flow in the intestinal contents of the GI. This would activate the secretory cell activity, releasing fluid and air which would then collect to the proximal site of the obstruction. As a
Short term: After 4 hours of nursing interventions, the patients pain will be minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10. Long Term: After 3 days of nursing interventions, the patient will be relieved from pain and will have vital signs within
To gain patients trust To obtain baseline data and to plan for the appropriate care Alteration in Vital signs is evident in the presence of pain To obtain information about the pain that the patient is manifesting
Short term: The pain shall have been minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10. Long Term: The patient shall have been relieved from pain and will have vital signs within normal limits.
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P-
result, fluid and air accumulation occurs and thus distension occurs. This distension would then cause pressure and irritation of the nerve endings within the intestinal mucosa
normal limits.
Serves as a comfort measure To decrease environment stimulus and promote rest To alleviate feeling of pain To lessen pain
Provide comfort measures Advise the patient to deep breathing exercises. Encourage patient to do diversional activities such as watching TV or talking to a family members Administer analgesics as prescribed
S- pain scale of 6/10 T-every time movement is elicited patient may manifest:
spiration
per sig
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spiration
per
Fear of the unknown is the most prevalent causes of preoperative anxiety. The patient experienced a vagua uneasy feeling of discomfort or dread accompanied by an autonomic response. A feeling of apprehension caused by anticipation of danger in surgery.
Short term: After 4 hours of nursing interventions, the patients pain will use resources and support system effectively. Long Term: After 4 days of nursing interventions, the patient will appear relaxed and report anxiety is reduced to a manageable level.
To know the patients condition and provide necessary actions and interventions. To obtain baseline data
Short term: The patients pain shall have used resources and support system effectively. Long Term: The patient shall have appeared relaxed and reported anxiety is reduced to a manageable level.
Monitor and record vital signs Observe the patients behaviour indicative of level of anxiety. Identify the patients coping skills and review coping
This can be a clue to the patients anxiety level To determine those that might be helpful in current
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skills in the past. Establish a therapeutic relationship, conveying empathy and unconditional positive regard. Acknowledge anxiety or fear.
circumstances
Do not deny or reassure patient that everything will be alright Helps patient to identify what is reality based
Provide accurate information about the situation Provide comfort measures such as providing calm/quiet environment, soft music and back rub.
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refill.
Establish individual needs/replace ment schedule Provide supplemental fluids as indicated Provide small frequent feedings Administer anti-emetic medications as ordered.
To prevent peaks and valleys in fluid level To maintain the nutritional needs of the patient To reduce patients vomiting episodes.
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S=
sig
ns and symptoms of inflammation at surgical site increase in vital sign signs and symptoms of shock
Short term: After 4 hours of nursing interventions, the patients surgery is performed using aseptic technique and in a manner to prevent cross contamination. Long Term: After 5 hours of nursing interventions, the patient will be free of signs and symptoms of infection.
To maintain a sterile field during the operation To know to the preventive measures to be taken To be able to administer prophylactic treatment Ensures that lessening of risk for infection To enable proper and early management of signs and
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after an invasive procedure. Minimizes the length of invasive procedure planning care. Administers prescribed prophylactic treatments. Administers care to wound sites.
symptoms To lessen occurrence or possibility of trauma and infection To provide pharmacological management for infection To minimize exposure of wounds to microorganisms
Problem # 2: Risk for Impaired Skin Integrity Related to Positioning, Immobilization, Pressure or Shearing Forces
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Assessment
Nursing Diagnosis
Scientific explanation
Objectives
Nursing Interventions
Rationale
Expected Outcome
S=
si gns and symptoms of inflammation at surgical site increase in vital sign Pressure sores Redness or blemishes
Risk for impaired skin integrity related to positioning, immobilization, pressure, and/or shearing forces
Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; potentiate the effects of pressure and hasten the development of skin breakdown. Improper positioning and surgical management during the operation can predispose the occurrence of
Short term: After 4 hours of nursing interventions, the patients skin remains smooth, intact, nonreddened, nonirritated, and free of bruising, other than surgical incision. Long Term: After 5 hours of nursing interventions, the patient will be free of signs and symptoms of physical injury.
Identifies physical alterations that may affect procedurespecific positioning. Positions the patient.
To determine extent of adjustment when performing positioning To ensure that the patient is comfortable and position is appropriate for the procedure To avoid trauma from external forces in the environment
Short term: The patients skin shall have remained smooth, intact, non-reddened, non-irritated, and free of bruising, other than surgical incision. Long Term: The patient shall have been free of signs and symptoms of physical injury.
Implements protective measures to prevent skin or tissue injury due to thermal, chemical, or mechanical sources.
To observe 79
Evaluates for signs and symptoms of injury to skin and tissue. Evaluates for signs and symptoms of injury as a result of positioning.
for any alterations in skin integrity To provide prompt management of identified signs and symptoms
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hills
Short term: After 4 hours of nursing interventions, the patients core body temperature will remain within expected range. Long Term: After 5 hours of nursing interventions, the patient will be at or return to normothermia at the conclusion of the immediate postoperative period.
To prevent a decrease in body temperature To monitor patients core temperature To perform appropriate measures and management Increases in ambient temperature are used to keep the peripheral tissue closer to target temperatures
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patient in to experiencing hypothermia because of his/her environment. Hypothermia is dangerous because it affects the body's core the brain, heart, lungs, and other vital organs. accidents. Severe hypothermia causes loss of consciousness and may result in death.
Problem # 1: Acute Pain R/T Disrupted Skin Integrity, Damaged Tissues and Nerves
Assessment Nursing Diagnosis Scientific explanation Objectives Nursing Interventions Rationale Expected Outcome
Acute pain r/t disrupted skin integrity, damaged tissues and nerves
cial grimaces
fa
ying
cr irr
itability
P-
Pain is an expected outcome postoperatively. And because pain is intensified with movement increase in discomfort is exhibited. Due to the presence of a surgical incision, continuity in the integrity of the skin is interrupted. The abundance of nerve endings in the skin makes it very sensitive to pain stimuli. Trauma such as cuts and incisions in invasive procedures post
Short term: After 4 hours of nursing interventions, the patients pain will be minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10. Long Term: After 3 days of nursing interventions, the patient will be relieved from pain and will have vital signs within normal limits.
To gain patients trust To obtain baseline data and to plan for the appropriate care Alteration in Vital signs is evident in the presence of pain To obtain information about the pain that the patient is manifesting Serves as a comfort measure
Short term: The pain shall have been minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10. Long Term: The patient shall have been relieved from pain and will have vital signs within normal limits.
Assess patients degree of pain every time she verbalizes pain Reposition patient
Provide quiet
To decrease 83
abdomen Spain scale of 6/10 T-every time movement is elicited patient may manifest:
erspiration
p si
operatively, the release of nociceptors that transmit pain stimuli and there is the release of chemicals such as histamine, bradykinin and prostaglandin that contributes to the experience of pain.
environment
Provide comfort measures Advise the patient to deep breathing exercises. Encourage patient to do diversional activities such as watching TV or talking to a family members Administer analgesics as prescribed
To lessen pain
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Problem # 2: Risk for Spread of Infection r/t Inadequate Primary Defenses (Broken Skin, Traumatized Tissue)
Nursing Diagnosis Scientific Explanation Expected Outcome
Assessment
Planning
Intervention
Rationale
S=
Risk for spread of infection r/t inadequate primary defenses (broken skin, traumatized tissue)
May manifest:
There are normal flora residing in our skin and these microorganisms are opportunistic in nature. As a result of the disruption in the skin integrity, these microorganisms may cause an increased risk to infection due to the break in the continuity of the skin, the bodys first line of defense. This disruption serves as a portal of entry for microorganisms.
Short Term: After 4 hours of nursing interventions, the client will be free from infection. Long Term: After 3 days of nursing interventions, the patient shall get rid or there shall be a total elimination of risk for infection.
To prevent the spread of microorganis ms, proper washing is a first line of defense against nosocomial infection. It may predispose the occurrence of infection since the hands are also carrier of microorganis ms. Prevent environmental contamination of fresh
Short Term: The risk for infection shall have been minimized Long Term: The patient shall have no infection AEB WBC within normal range
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soiled dressing
wounds Encourage patient to increase fluid intake To prevent possible recurrence of infection
re
pr
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Problem # 3: Risk for Aspiration Related to Impaired Swallowing Due to Previous Placement of Nasogastric Tubing
Nursing Diagnosis Scientific explanation Nursing Interventions Assessed patients overall status Noted amount and rate of food and fluid intake from all sources Expected Outcome Short term: The patient will demonstrate techniques to prevent aspiration such as sitting upright and eating slowly. Long term: The patient will be free from aspiration.
Assessment
Objectives
Rationale
O- patient manifested: coughing after drinking shortness of breath and easy fatigability when eating needs assistance when drinking
Risk for aspiration related to impaired swallowing due to previous placement of nasogastric tubing
To prevent aspiration and gas distension, a NGT is placed. When this tube is inserted and removed, the tubing leads to trauma of the esophagus, making it difficult for the patient to swallow properly. Aspiration happens when food, liquid, or any material blocks or enters the air passages, leading
Short term: After 4 hours of NPI the patient will demonstrate techniques to prevent aspiration such as sitting upright and eating slowly. Long term: After 3 days of NPI the patient will be free from aspiration.
To obtained baseline data for future references. to monitor patients daily intake.
Placed in semi To facilitate fowlers position as movement of appropriate diaphragm, improving respiratory effort Advise the patient to maintain an upright position when eating. Encourage the client to eat food To facilitate swallowing
and eating
to compromised breathing.
Assessment
Objectives
Rationale
O- patient manifested: weak posture inability to maintain balance pale slow movement
Activity intolerance is a condition of the body where there is insufficient physiological or psychological means or capability to endure or complete the required or desired daily activities. Depression can be one of the factors that may increase or contribute to general weakness and may lead to
Short term: After 4 hours of NPI the patient will be able to use and identify techniques to enhance activity
To obtained baseline data for future references. To identify more causative or precipitating factors
Long term: After 3 days of NPI the patient will demonstrate a measurable increase in activity.
Note the pts report of weakness, fatigue or difficulty accomplishing tasks Provide adequate rest periods Increase activity levels gradually Assist the pt in
Short term: The patient shall have used and identified techniques to enhance activity. Long term: The patient shall have demonstrated a measurable increase in activity.
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inability of the person to participate in the activities of daily living. Tolerance to activity wil be compromised for a patient experiencing a disease condition.
injury
To enhance ability to participate in activities To indicate the need to alter activity level To promote wellness and proper circulation To treat underlying factors
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Assessment
Planning
Intervention
Rationale
S = Ano naba nyan ang mangyayari sakin.? as verbalized by the pt. O= Patient manifested Restlessness Appears tense High blood pressure Patient may manifest:
Increased RR
Anxiety is a vague uneasy feeling of discomfort or dread accompanied by an autonomic response or a feeling of apprehension caused by anticipation of danger. Due to the lack of knowledge about the disease condition, the patient is not aware or is having difficulty adjusting about
Short Term: After 3 hours of Nursing Interventions the patient will be able to identify ways to reduce anxiety.
To gain clients trust and participation To obtain baseline data In order to know the manageability of anxiety and provide appropriate intervention Limited knowledge of the unknown results may cause anxiety to the patient
Short Term: The patient shall have identified ways to reduce anxiety.
Long Term: After 2 days of Nursing Interventions patient will demonstrate reduction of anxiety into manageable
Long Term: Patient shall have demonstrated reduction of anxiety into manageable levels 90
Muscle tension
Diaphoresis
the levels manifestations of the disease. Thus the patient is afraid on what will happen to her condition as the disease progresses.
Teach the pt proper breathing exercises Instruct the patient to do diversional activities Collaborat e with other professionals
Deep breathing exercises can reduce tension To divert focus to other things Collaboration promotes the best long range plan to attain success for the health of the patient Helps to relax the patient if necessary and uncontrollable
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