Chapter IX Nursing Care Plan

Nursing Care Plan 1 DIAGNOSIS NEED DESIRED OUTCOMES INTERVENTION RATIONALE EVALUATION MODIFIED INTERVENTI ON RATION ALE

Acute Pain r/t disease process secondary to Acute Gouty Arthritis Subjective cue: Sakit lang gid maghulag. Indi ko makalakat kay masakit, as verbalized by the patient. -With Pain Scale of 7 where 10 is the highest pain perceived and 1 is the lowest. Objective cues: Facial grimace elicited, pale. Skin warm to touch Irritability noted due to discomfort from pain.

P H Y S I O L O G I C N E E D

After 8 hours of nursing intervention: General Objective: Report pain is relieved or controlled and promote wellness Specific: a. Express understanding of situation and individual treatment regimen and safety measures. b. Decrease Pain Scale from 7 to 5 where 10 is

INDEPENDENT: Goal Met: a. Able to cooperate with the procedures done but still has limited ability to express feelings and perception because of Aphasia.

a. Urge the client to drink 2 to 3 L of fluid daily and to report any decrease in urine output. b. Asses level of pain felt.

To monitor any abnormaliti es in input and output.

To determine how intense the pain felt.

c. Provide measure to promote comfort and reduce pain.

b. Pain Scale decreased from 7 to 5 where 10 is the highest pain perceived and 1 is the To alleviate lowest. pain when present. Nonpharmacol

VS: T: 37.5C CR:80 bpm R:27cpm BP:120/70 mmHg Background knowledge: Formation of tophus deposits in soft tissues

the highest pain perceived and 1 is the lowest. c. Maintain or increase strength and function of affected and/or compensatory body part. d. Assess patient in performing deep breathing measures to promote relaxation

ogic therapies can also lessen any pain felt. d. Teach the client about dietary modifications to limit foods high in purine (e.g. organ meats, anchovies, sardines, shellfish, chocolate, meat extracts).

Avoiding food that may trigger disease may lessen d. Able to relax by performing the chance deep breathing of measures recurrence.

c. Able to control or alleviate pain of affected incised part through resting and acquiring therapeutic regimen.

Affects joints in the knees and ankles Pain occurs Gouty arthritis is a metabolic disease marked by urate crystal deposits in the joints throughout the body, causing local irritation and inflammatory responses.

e. Maintain strict bed rest for 24 hours after an attack.

Providing comfort may lessen chance of re occurrence of pain.

Source: Nursing Care Plans (Nursing Diagnosis and Intervention 6th Edition by: Gulanick/ Myers

DEPENDENT: Administer prescribed medications, which may include nonsteroidal antiinflammatory drugs, uric acid synthesis inhibitors, and uricosuric agents. Carry out new orders during rounds of physician Medication is the most important thing to be performed, to reduce or eliminate pain felt by the patient.

To perform nursing procedures that allay needs of patients

COLLABORATIVE: Maintain a safe and clean environment To promote fast recovery and comfort of patient through

rehydration and use of therapeutic regimen to uphold healing

DIAGNOSIS Activity intolerance related to generalized weakness as evidenced by: Subjective Cues: Indi ko ka tarong tindog kag maghulag sing tarong kay luya akong lawas, Objective Cues:
With limited ROM Unable to ambulate Body weakness noted Unable to flex and extend knees freely Decreased lower extremity strength

NEED P H Y S I O L O G I C N E E D S

DESIRED OUTCOME After 8 hours of nursing intervention, the patient will be able to:

NURSING INTERVENTIONS Independent: Assess presence of factors contributing to fatigue

RATIONALE

EVALUATION

MODIFICATION

To assess factors affecting current situation

GENERAL: Increase in activity tolerance SPECIFIC:

Assess if assistance is needed from another person Encourage active

To prevent injury to patient to maintain muscle

Goal partially met. After 8 hours of nursing intervention, the patient was able to increase activity tolerance but still needs assistance when doing a certain task.

- Identify negative factors affecting activity tolerance

Note patients report of weakness, fatigue, pain and any difficulty of accomplishing task

Symptoms may be result or contribute to intolerance of activity

Monitor vital signs

To baseline data and to assist patient to deal with contributing factors and manage activities within individual limits.

VITAL SIGNS: T- 37.8 C P- 84bpm R- 16cpm BP- 120/60mmHg Background knowledge:

assess nutritional
status

adequate energy reserves

Ascertain ability to - Use identified stand and move techniques to enhance about and degree activity tolerance of assistance necessary

To determine current status and needs associated with participation in desired activities

Decreased activity tolerance

Assist with activities To protect patient from and injury provide/monitor clients use of assistive devices such as crutches, walker, or wheelchair

Activity Intolerance

- Report measurable increase in activity tolerance

Activity intolerance means there is insufficient physiological or psychological energy to endure or complete required or

Promote wellness To indicate the need to - Instruct client/ SO alter activity level in monitoring response to activity

- Assist patient in learning and demonstrating appropriate safety measures

To prevent injuries

desired daily activities (NANDA, 2008).

- Encourage patient to maintain positive attitude

To enhance sense of well-being

DIAGNOSIS

NEED

DESIRED OUTCOMES

INTERVENTION Independent:

RATIONALE

EVALUATION

Diagnosis: Self-care deficit RT musculoskeletal impairment secondary to gouty arthritis. Subjective cues: Akong anak pa og asawa ang nagapaligo og nagabihis sa akua as verbalized by the patient.

P H Y S I O L O G I C N E E D

After 8 hours of nursing intervention: General: Provide relief and promote wellness e. Express understanding of situation and individual treatment regimen and safety measures. f. Perform PROM by flexing arms and legs and turn to sides with assistance from folks and SN. Assessed the clients activity to bathe self via direct observation using physical performance tests for ADLs

Observation of bathing performed in an atypical bathing setting may result in false date for which use of a physical performance test compensates to provide more accurate ability data. Support physical/ emotional independence.

Goal Partially Met:

e. Able to flex arms and legs as well as turn to sides with assistance from folks and SN f. Able to increase strength of affected body part through resting and acquiring therapeutic regimen.

Objective data: Inability to feed self independently Inability to dress self independently Inability to bathe and groom self independently Inability to perform toileting tasks

Maintain mobility, pain control, and exercise program. Assess barriers to participation in self-care. Identify/ plan for environmental modifications. Allow client sufficient time to complete tasks

g. Maintain or increase strength and function of affected and/or compensatory body part.

Prepares for increased independence, which enhances self-esteem. May need more time to complete tasks by self but provides an

g. Able to relax by performing deep breathing measures

independently Inability to ambulate independently

to fullest extent of ability. Capitalize on individual strengths. Taught use of adaptive bathing equipment and follow up in home. Collaborative:

opportunity for greater sense of self-confidence and self-worth. Adaptive devices extend the clients reach, increases speed and safety, and decrease exertion and reduce caregiver burden.

VS: T: 37.5C P:70 bpm R:27cpm BP:120/70 mmHg

Background knowledge: Musculoskeletal impairment Decreased strength Pain on movement Self-care deficit

Consult with rehabilitation specialists; e.g., occupational therapist.

Arrange homehealth evaluation before discharge, with follow-up afterward.

Helpful in determining assistive devices to meet individual needs; e.g., button hooks, longhandled shoehorn, reacher, hand-held shower head. Identifies problems that may be encountered because of current level of disability. Provides for more successful team efforts with others who are involved in care; e.g.,

Circumstances where individuals have failed to implement or complete

ability bathing / hygiene activities. SOURCE: Nursing Care Plans (Nursing Diagnosis and Intervention 6th Edition by: Gulanick/ Myers Arrange for consult with other agencies; e.g., Meals on wheels, home care services, nutritionist.

occupational therapist. May need additional kinds of assistance to continue in home setting.