CHAPTER 8 NURSING CARE PLAN

ASSESSMENT SUBJECTIVE: Nganong perme ko malipung as verbalized by the pt.

DIAGNO SIS Risk for prone behavior r/t lack of knowledge about the disease.

OBJECTIVE: -request information -agitated behavior -inaccurate follow through of instructions. -VS taken as follow T: 38.4 P: 105 R: 23 BP: 160/100

PLANNING After 4 hours of nursing intervention patient will verbalized understanding of disease, process and treatment regimen.

INTERVENTION >Defined and stated the limits of desired BP, explain hypertension and its effect on the heart, blood vessels, kidney and brain.

>Assisted the patient in identifying modifiable risk factors like high sodium diet, saturated fats and cholesterol. >Reinforced the importance of adhering the treatment regimen and keeping follow up appointment.

RATIONALE >Provides bases for understanding elevations of Blood pressure, and clarifies misconceptions and also understanding that BP can exist without symptoms or even when feeling well. >These risk factors have been shown to contribute to hypertention.

EVALUATION Goal met -After 4 hours of nursing intervention the patient was able to verbalized understanding of the disease process & treatment regimen.

>Lack of cooperation is common reason for failure of anti hypertensive

>Suggest frequent position changes, leg exercises when lying down.

therapy.

>Help patient identify sources of sodium intake.

>Decrease peripheral venous pooling that maybe potentiated by vasodilators and prolonged sitting or standing. >Two years of moderate low salt diet maybe be sufficient to control hypertension. >Caffeine is a cardiac stimulant and adversely affect cardiac function. >Alternating rest inactivity increases tolerance to activity progression.

>encouraged patient to decrease on eliminate caffeine like in tea , coffee, cola and chocolates. >Stressed importance of accomplishing daily rest periods.

DEPENDENT: >Provide information regarding community resources and

support patients >Community in making lifestyle resources like changes. health center programs and check ups are helpful in controlling hypertension.

ASSESSMENT SUBJECTIVE: - wala pako naka libang sugad ganina buntag

DIAGNOSIS constipation related to voiding incontinence.

PLANNING After 4 hrs of nursing intervention, the patient will verbalize understanding the etiology and

INTERVENTION - Educate patient/

RATIONALE - Information can

EVALUATION Goal Met the patient verbalized understanding about constipation and gained knowledge of appropriate intervention.

SO about safe and help client to make risky practices for managing constipation. beneficial choices when need arises.

OJECTIVE: - Decreased

appropriate intervention if constipation

- Instruct balance fiber and bulk in diet and fiber supplements.

- To improve consistency of stool and facilitate passage through colon.

ambulation of may occur. the patient bcs of pain and the complete bed rest ordered of the physician.

- Promote adequate fluid intake, also - To promote soft stool and stimulate

suggest drinking warm fluids.

bowel activity.

- Encourage activity within limits of individual ability.

-To stimulate constrictions of the intestines

ASSESSMENT SUBJECTIVE: murag nagabug`at man ang akong timbang as verbalized by the patient.

DIAGNOSIS Decreased cardiac output r/t decreased venous return

OBJECTIVE: -variations in BP -edema -VS taken as follows T: 37.5 P: 87 R: 22 BP:120/100

PLANNING After 6 hours of nursing intervention the patient will participate in activities that reduce blood pressure or cardiac work load.

INTERVENTION INDEPENDENT: >Monitor blood pressure of the pt. Measure in both arms or thigh three time, 3-5 minutes apart while pt is at rest, then standing for initial evaluation. >Observe, skin, color, moisture, temperature & capillary time

RATIONALE >Comparison of pressures a more complete picture of vascular involvement or scope of the problem.

>Note dependent or general edema >provide calm, rest full surroundings, minimize environmental activity or noise. >Maintain activity restrictions

>Presence of pallor, cool, moist skin, & delayed capillary refill time maybe due to peripheral vasoconstriction >May indicate heart failure renal or vascular impairment. >Help reduce sympathetic stimulation, promotes relaxation >Reduces physical stress & tension that affect blood pressure & course of

EVALUATION Goal met After 6 hours of nursing intervention the patient was able to participate in activities that reduce blood pressure or cardiac workload.

>Instruct in relaxation &

guided imagery.

DEPENDENT: >Implement dietary sodium, fat, & cholesterol restrictions as indicated

hypertension >Can reduce stressful stimuli produce calming effect, thereby reduce blood pressure. >These restrictions can help manage fluid retention & with associated hypertensive response, which decrease cardiac workload.

ASSESSMENT Subjective: Luya kaayo akong paminaw. Maski sige lang ko ug tulog kay kapoie gihapon akong ginabati as verbalized by the patient.

DIAGNOSIS Fatigue related to poor physical condition

PLANNING At the end of 1 day span of nursing care, the patient will be able to:- report improved sense of energyperform ADLsparticipate in desired activities

INTERVENTION 1. Teach energy conservation principles.

RATIONALE 1.Patients and care giver may need to learn skills for delegating tasks to

EVALUATION At the end of 1 day span of nursing gcare, the patient was able to:-

others, setting priorities Report improved and clustering care to sense of use available energy to energyArangcomplete desired activities. arang na akong paminawas verbalized by 2.Stress the importance of 2. Energy reserves may be depleted unless the patient respects the body need for increased rest. patient.

Objective:

at level of ability

=Weakness =Lack of energy =Pale skin =Decreased muscle strength

frequent rest periods

3. Observe the patient usual level

3. Both increased physical exertion and

of exercise and physical activity.

limited levels of exercise can contribute to fatigue.

4. Assist the patient to develop a schedule for daily activity and rest.

4. A plan that balances periods of activity with periods of rest can help the patient complete desired activities without adding to levels of fatigue.

ASSESSMENT Subjective: Sakit kaayo ang akong tiyan sa bandang baba as verbalized by the patient.

DIAGNOSIS Acute pain r/t to epigastric pain

PLANNING After 2hrs. span of care patient pain will be relief or

INTERVENTION 1.observed and document location of the pain, scale(010) and character of

RATIONALE 1.Provide information about disease progression, development of complication and

EVALUATION After 2hrs. span of care patient pain was relief and controlled as the evidence of pain scale of 3 out of 10.

controlled as the pain. evidence of pain scale 7 out of 2.Promote bed rest.

effectiveness of intervention

Objective:

10. 3.Encourage of use

=Grimaced face noted =Narrowed focus guarding behaviour =pain scale of 7 out of 10.

relaxation techniques. 2.To reduce intraabdominal pressure 4.Control environmental pressure. 3.To promote rest ,redirect attention, may enhance 5.Administered medication as physician ordered. 4.To minimize dermal discomfort. coping.

5.To reduce severe pain, promotes and relax smooth muscle.

ASSESSMENT Subjective: Naga luya ko pero dali lang kaayo ko kapuyon as verbalized by the patient.

DIAGNOSIS Risk for Activity

PLANNNING After 8hrs of

INTERVENTION Assess patients ability to perform normal task or activities of daily living.

RATIONALE Influences choice of interventions or needed assistance

EVALUATION After 8hrs of nursing intervention the patient was able to reveals an

in Tolerance r/ t nursing body weakness intervention the patient will Report an increase an activity in tolerance

May indicate Note changes in balance/ gait disturbance, neurological changes associated with vitamin B12deficiency, affecting patient safety or risk of injury.

increase inactivity tolerance.

Objective: =Body malaise noted = look tired =pale skin noted =With fatigability

including

activities of daily muscle weakness. living.

Recommend quiet atmosphere, bed rest if indicated.

Enhances rest to lower bodys oxygen requirements, and reduces strain on the heart and lung

Elevate the head of the bed as tolerated.

Enhances lung expansion to maximize oxygenation for cellular uptake.

Provide or recommend assistance with activities or ambulation as necessary, allowing patient to do as much as possible

Although help maybe necessary, self esteem is enhanced when patient does some things for self.

ASSESSMENT SUBJECTIVE: Init kayo kayo dire ma`am sabah pa jud as verbalized OBJECTIVE: >irritability >elevated blood pressure >VS taken as follow T: 38.4 P: R: BP:140/90

DIAGNOSIS Risk for seizure r/t environmental factor & stressor

PLANNING After 1 hour of nursing intervention the patient will able to understand the risk factor of seizure.

INTERVENTION >Encouraged verbalization of feelings & perception regarding her present Condition. >Educate client regarding risk factors of seizure >Determined factors r/t individual situation, as listed in risk factor, & extent of risk. >Assess influence of clients lifestyle & stress on potential for seizure. >Reviewed diagnostic studies & laboratory test for imbalances. >provided seizure precaution. >Kept bed in low position as appropriate. >Encouraged

RATIONALE >To assess the knowledge of the patient regarding her present condition. >Able to demonstrate understanding for her benefit. >Influences scope and of interventions to manage threat to safety.

EVALUATION Goal Met The patient demonstrate and able to verbalize understanding regarding the risk or the factors that may lead to seizure.

>That may result in or exacerbate conditions.

>to prevent injury or fall if seizure

divertional activities such as chatting to other patient`s. >provided comfort.

occur. >To divert her attention and lessen stressors.

>for patients comfort

ASSESSMENT SUBJECTIVE: wala ko kaihi sukad gahapon

DIAGNOSIS Impaired urinary elimination

OBJECTIVE: - low urine output for 8 hours 100cc - with foly catheter - edema Urinalysis: Color: Light Yellow Appearance: Clear Reaction: 8 Specific gravity: 1.05 PUS CELL: 0-5 Sugar: (-) Albumin: (+) Protein: +3 (0.5g)

PLANNING After 4 hours of nursing intervention the patient will achieve normal urine elimination pattern or participate in measure to correct or compensate for deffects.

INTERVENTION >Determined client usual daily fluid intake. Note condition of skin in mucus membranes, color of urine. >Ascertain clients previous pattern of elimination. >Have client keep a voiding dairy for 3 days to record fluid intake, voiding times, precise urine output, in dietary intake. >Encourage fluid intake up to 3000cc or more per day, including cranberry juice.

RATIONALE >To help determined level of dehydration.

EVALUATION Goal Partially Met The patient was able to compensate but normal urine elimination pattern was not achieved.

>For comparison with current situation. >helps determined baseline symptoms, severity of frequency or urgency, in whether diet is a factor. >To help maintain renal function, prevent infection and formation of urinary stones, avoid encrustation around catheter, or flushing urinary diversion appliance.

>Check frequently for

bladder distention and observe for overflow

To reduce risk of infection and/or automatic hyperrelfexia.

Assessment Subjective: nagainit akoang lawas, mura man kug gi hilantan oi, kapoy pa gyud mu lihok As verbalized by the patient Objective: Dry skin Warm to touch Dry lips Irritable Temp: 38.4

Nursing Diagnosis Hyperthermia related to invasion of infection.

Planning After 4 hours of completing the nursing intervention, the patients body temperature must fall within the normal range of 37.4

Intervention Independent: Establish Rapport Health teaching to the watcher regarding the proper way of taking care of the patient while on hyperthermia Apply TSB Promote surface cooling by loosening the clothes Assess fluid loss and facilitates oral fluid intake to accomplish fluid replacement

Rationale To gain trust

Evaluation

After 2 days of performing intervention, goal was partially met, To educate and the watcher has supply gained information knowledge about hyperthermia and the patients body Promote heat loss temperature by evaporation decreased from and conduction 38.4 to 37.4 Increase metabolic rate and diaphoresis associated with fever

Dependent: Administer Paracetamol as prescribed. Medicine to reconcile rise of temperature.