Intestinal Obstruction Nursing Care Plan 4g4b5q
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Chapter IX NURSING CARE PLAN
DIAGNOSIS
NEED
Acute pain r/t surgical incision as manifested by verbalization of perceived pain around the surgical site, and slight facial grimacing
P H Y S I O L O G I C
Cues: Subjective: >After operation, she verbalized, “Akong tahi, nagasakit pa.” >Felt pain around the surgical site >Believes that pain felt is due to postoperative experience Objective:
N E E D
DESIRED OUTCOME Within 8 hours of Nursing Interventions, >Manage Pain by following prescribed pharmacologic regimen and be relieved by nursing interventions >Take a rest and sleep
INTERVENTIONS
RATIONALE
INDEPENDENT Establish rapport to the patient
To gain client’s trust and cooperation
Monitor vital signs frequently and interpret it accurately
To see
Assess location, intensity, and aggravating factors at frequent interval by the patient’s selfreported pain
For accurate assessment of pain
Assess for behavioral and physiological responses to
These are potential indicators of pain in
trends including progress of condition or any unusual signs
EVALUATION STATEMENT Goal Partially Met. Reduced complaint of pain Claimed that pain is already subsiding Was able to take rest periods
INTERVENTIONS Continue Nursing Interventions especially monitoring vital signs, assessing characteristics of pain, providing comfort measures, health teachings, and providing quiet environment and wellventilated area ister analgesics as ordered/prescr ibed
RATIONALE To decrease pain felt To provide comfort To prevent fatigue To enhance self-image
For faster relief of pain
>Slight facial grimacing >Vital Signs: T=360 C PR=70 bpm RR=18 m BP=120/70 mmHg
Background Knowledge: Most patients experience pain after a surgical procedure. Complete absence of pain in the area of the surgical incision may not occur for a few weeks, depending on the site and nature of the surgery, but the intensity of postoperative pain gradually subsides on subsequent
135
pain
Do bedside care Provide with rest intervals with quiet environment and wellventilated area
patients who are unable to self-report To provide comfort To prevent fatigue
Position comfortably
Provide comfort measures such as massaging of hands or back and by staying with the patient
To relieve discomfort caused by pressure and to improve circulation
To enhance self-image and divert the attention of the patient
Render health teachings which may be helpful after discharge such as not lifting heavy objects,
To let patient manage condition in the most careful manner
days. About 1/3 of patients report severe pain, 1/3 moderate pain, 1/3 little or no pain. They appear to activate psychodynami c mechanisms that impair the ing of pain (“gate closing”) theory and nociceptive transmission). Reference: Brunner & Suddarth. Textbook of Medical – Surgical Nursing. Ed 12. Vol. 1
136
ambulate with assistance, proper wound dressing, hygienic care, and to report pain as soon as it begins Implement use of Range of Motion Exercises, and relaxation
To reduce drug therapy as possible; however, these may add to the action of pharmacolog ic regimen
DEPENDENT ister analgesics IVTT as prescribed
To have quick time for onset of relieving pain, patient is for NPO
DIAGNOSIS Fatigue r/t postoperative experience as manifested by evidence of weakness and deep sleep Cues: Objective: >After operation, patient is on bed rest >Flat on bed and shows evidence of weakness >Steady and in deep sleep for 4 hours >Vital Signs: T=360 C PR=70 bpm RR=18 m BP=120/70 mmHg
137
NEED
P H Y S I O L O G I C N E E D
DESIRED OUTCOME Within 8 hours of Nursing Interventions,
>Demonstrate improved level of energy specifically to participate in therapeutic activities at level of ability
INTERVENTIONS
RATIONALE
INDEPENDENT Establish rapport to the patient
To gain client’s trust and cooperation
Monitor vital signs frequently and interpret it accurately
To see trends including progress of condition or any unusual signs
EVALUATION STATEMENT Goal Met. Was able to demonstrate improved level of energy by having rest periods Appeared relax and calm
Cooperates >Restore energy through rest intervals
Provide with rest intervals with quiet environment and wellventilated area Provide comfort measures such as massaging of hands or back and by staying with the patient
To prevent fatigue
To enhance self-image
during istratio n of medication
INTERVENTIONS Retain Nursing Interventions
RATIONALE To continue progress of improving patients level of energy
Background Knowledge:
Implement use of Range of Motion Exercises, and relaxation
Fatigue is common after major surgery and delays recovery. It is usually attributed to the physiologic al response to surgery. Fatigue is a common health complaint. It is, however, one of the hardest to define, and a symptom of many different conditions. Fatigue, also known as weariness, tiredness, exhaustion or lethargy, is generally
138
Provide patient with opportunities for expressing feelings of irritation, weakness, or discomfort Assist patient with setting and achieving goals Enhance patient’s power resources by fostering patient involvement in decision making by enabling patient to control environment as appropriate
Assess and
To promote level of energy by conducting exercise and promoting circulation To let the patient feel you are concerned and she’s not alone
To foster hope and bring back her liveliness For patient’s fast recovery and for her to gain confidence and enhance strength within self
defined as a feeling of exhaustion and decreased capacity for physical and mental work
Reference: http://www.emedici nehealth.com/fatigu e/article_em.htm December 23, 2010
139
motivate patient’s abilities to be an active participant in self-care
For the patient to recover as soon as possible
DEPENDENT ister medicines as prescribed
To provide comfort to client as well as alleviate fear and anxiety
DIAGNOSIS
NEED
DESIRED OUTCOME
INTERVENTIONS
RATIONALE
EVALUATION STATEMENT
INTERVENTIONS
RATIONALE
INDEPENDENT Establish rapport to the patient Altered comfort secondary to pain as manifested by frequent sighing and complaints of pain
Monitor vital signs frequently and interpret it accurately
Cues:
To gain client’s trust and cooperation To see trends including progress of condition or any unusualities
Objective: Encourage diversional activity like listening to music
>Frequent sighing >Complaints of pain surrounding the surgical site >Can respond to stimuli verbally and physically with weakness noted
Provide with rest intervals with quiet environment and wellventilated area
>Vital Signs: T=360 C PR=70 bpm RR=18 m BP=120/70 mmHg
Background Knowledge:
Knowing 140
that someone you care about has just gone through surgery can make
Within 8 hours of Nursing Interventions,
P H Y S I O L O
>Enhance comfort by resting and sleeping
Provide comfort measures such as massaging of hands or back and by staying with the patient Implement use of Range of Motion Exercises, and relaxation
Provide patient
To provide coping stress to alleviate the fatigue felt by the client To prevent fatigue
To enhance self-image
Goal Met
The patient was able to have a deep sleep for 4 hours
To promote level of energy by conducting exercise and promoting circulation
Continue providing comfort measures and rest intervals
To bring back the patient’s energy loss and to restore proper body functions
DIAGNOSIS
NEED
Acute pain r/t surgical incision as manifested by verbalization of perceived pain around the surgical site, and slight facial grimacing
P H Y S I O L O G I C
Cues: Subjective: >After operation, she verbalized, “Akong tahi, nagasakit pa.” >Felt pain around the surgical site >Believes that pain felt is due to postoperative experience Objective:
N E E D
DESIRED OUTCOME Within 8 hours of Nursing Interventions, >Manage Pain by following prescribed pharmacologic regimen and be relieved by nursing interventions >Take a rest and sleep
INTERVENTIONS
RATIONALE
INDEPENDENT Establish rapport to the patient
To gain client’s trust and cooperation
Monitor vital signs frequently and interpret it accurately
To see
Assess location, intensity, and aggravating factors at frequent interval by the patient’s selfreported pain
For accurate assessment of pain
Assess for behavioral and physiological responses to
These are potential indicators of pain in
trends including progress of condition or any unusual signs
EVALUATION STATEMENT Goal Partially Met. Reduced complaint of pain Claimed that pain is already subsiding Was able to take rest periods
INTERVENTIONS Continue Nursing Interventions especially monitoring vital signs, assessing characteristics of pain, providing comfort measures, health teachings, and providing quiet environment and wellventilated area ister analgesics as ordered/prescr ibed
RATIONALE To decrease pain felt To provide comfort To prevent fatigue To enhance self-image
For faster relief of pain
>Slight facial grimacing >Vital Signs: T=360 C PR=70 bpm RR=18 m BP=120/70 mmHg
Background Knowledge: Most patients experience pain after a surgical procedure. Complete absence of pain in the area of the surgical incision may not occur for a few weeks, depending on the site and nature of the surgery, but the intensity of postoperative pain gradually subsides on subsequent
135
pain
Do bedside care Provide with rest intervals with quiet environment and wellventilated area
patients who are unable to self-report To provide comfort To prevent fatigue
Position comfortably
Provide comfort measures such as massaging of hands or back and by staying with the patient
To relieve discomfort caused by pressure and to improve circulation
To enhance self-image and divert the attention of the patient
Render health teachings which may be helpful after discharge such as not lifting heavy objects,
To let patient manage condition in the most careful manner
days. About 1/3 of patients report severe pain, 1/3 moderate pain, 1/3 little or no pain. They appear to activate psychodynami c mechanisms that impair the ing of pain (“gate closing”) theory and nociceptive transmission). Reference: Brunner & Suddarth. Textbook of Medical – Surgical Nursing. Ed 12. Vol. 1
136
ambulate with assistance, proper wound dressing, hygienic care, and to report pain as soon as it begins Implement use of Range of Motion Exercises, and relaxation
To reduce drug therapy as possible; however, these may add to the action of pharmacolog ic regimen
DEPENDENT ister analgesics IVTT as prescribed
To have quick time for onset of relieving pain, patient is for NPO
DIAGNOSIS Fatigue r/t postoperative experience as manifested by evidence of weakness and deep sleep Cues: Objective: >After operation, patient is on bed rest >Flat on bed and shows evidence of weakness >Steady and in deep sleep for 4 hours >Vital Signs: T=360 C PR=70 bpm RR=18 m BP=120/70 mmHg
137
NEED
P H Y S I O L O G I C N E E D
DESIRED OUTCOME Within 8 hours of Nursing Interventions,
>Demonstrate improved level of energy specifically to participate in therapeutic activities at level of ability
INTERVENTIONS
RATIONALE
INDEPENDENT Establish rapport to the patient
To gain client’s trust and cooperation
Monitor vital signs frequently and interpret it accurately
To see trends including progress of condition or any unusual signs
EVALUATION STATEMENT Goal Met. Was able to demonstrate improved level of energy by having rest periods Appeared relax and calm
Cooperates >Restore energy through rest intervals
Provide with rest intervals with quiet environment and wellventilated area Provide comfort measures such as massaging of hands or back and by staying with the patient
To prevent fatigue
To enhance self-image
during istratio n of medication
INTERVENTIONS Retain Nursing Interventions
RATIONALE To continue progress of improving patients level of energy
Background Knowledge:
Implement use of Range of Motion Exercises, and relaxation
Fatigue is common after major surgery and delays recovery. It is usually attributed to the physiologic al response to surgery. Fatigue is a common health complaint. It is, however, one of the hardest to define, and a symptom of many different conditions. Fatigue, also known as weariness, tiredness, exhaustion or lethargy, is generally
138
Provide patient with opportunities for expressing feelings of irritation, weakness, or discomfort Assist patient with setting and achieving goals Enhance patient’s power resources by fostering patient involvement in decision making by enabling patient to control environment as appropriate
Assess and
To promote level of energy by conducting exercise and promoting circulation To let the patient feel you are concerned and she’s not alone
To foster hope and bring back her liveliness For patient’s fast recovery and for her to gain confidence and enhance strength within self
defined as a feeling of exhaustion and decreased capacity for physical and mental work
Reference: http://www.emedici nehealth.com/fatigu e/article_em.htm December 23, 2010
139
motivate patient’s abilities to be an active participant in self-care
For the patient to recover as soon as possible
DEPENDENT ister medicines as prescribed
To provide comfort to client as well as alleviate fear and anxiety
DIAGNOSIS
NEED
DESIRED OUTCOME
INTERVENTIONS
RATIONALE
EVALUATION STATEMENT
INTERVENTIONS
RATIONALE
INDEPENDENT Establish rapport to the patient Altered comfort secondary to pain as manifested by frequent sighing and complaints of pain
Monitor vital signs frequently and interpret it accurately
Cues:
To gain client’s trust and cooperation To see trends including progress of condition or any unusualities
Objective: Encourage diversional activity like listening to music
>Frequent sighing >Complaints of pain surrounding the surgical site >Can respond to stimuli verbally and physically with weakness noted
Provide with rest intervals with quiet environment and wellventilated area
>Vital Signs: T=360 C PR=70 bpm RR=18 m BP=120/70 mmHg
Background Knowledge:
Knowing 140
that someone you care about has just gone through surgery can make
Within 8 hours of Nursing Interventions,
P H Y S I O L O
>Enhance comfort by resting and sleeping
Provide comfort measures such as massaging of hands or back and by staying with the patient Implement use of Range of Motion Exercises, and relaxation
Provide patient
To provide coping stress to alleviate the fatigue felt by the client To prevent fatigue
To enhance self-image
Goal Met
The patient was able to have a deep sleep for 4 hours
To promote level of energy by conducting exercise and promoting circulation
Continue providing comfort measures and rest intervals
To bring back the patient’s energy loss and to restore proper body functions
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