I. II. B. PLANNING (NURSING CARE PLANS)

Problem # 1: ACUTE PAIN

Assessment

Nursing Diagnosis

Scientific Explanation

Objectives Intervention RationaleExpected outcome

S: O O: The patient may manifest:> Pain on the gastric area>pain scale of 8/10>(+) facial grimaces>(+) guarded behavior>restlessness>cold clammy skin>limited movement

Acute pain acute pain starts with the stimulation of one or more of the many special sense receptors, called nociceptors, in the skin. These receptors receive information about tissue trauma or other events that can cause body damage. Two types of nerve fibers carry this information from the nociceptors to the spinal cord: A-delta fibers, which transmit information quickly and appear to be responsible for the acute sense of pain; and C-type fibers, which transmit

Short term:After 4 hours of nursing interventions, the patient will be able to verbalize a reduction of pain AEB decreased pain scale of 8/10 to 4/10, reduction of facial grimaces, guarding behavior (−)cold clammy skin, and (−) restlessness.

Long term: After 2 weeks of

>Establish rapport.

>Assess, monitor and record vital signs.

>Encourage verbalization of feelings about the pain.

>To facilitate health care intervention and promote participation and compliance to treatment regimen.

>To get baseline data and to note progress of patients condition.

>To assist the client to explore methods of alleviation or control of pain. Listening to the patient respectfully and implying an alliance against pain help reduce anxiety.

Short term:The patient shall have verbalized a reduction of pain AEB decreased pain scale of 6/10 to 4/10, reduction of facial grimaces, guarding behavior (−)cold clammy skin, and (−) restlessness.

Long term:The patient shall have verbalized a total relief of pain AEB

>self-focusing>narrowed focus

impulses more slowly and may cause the nagging sense of pain. At the spinal cord, messages from nociceptors may be modulated by other spinal nerves that enhance or, more frequently, diminish the intensity of the pain stimulus. The impulse then travels to several parts of the brain. Some brain areas determine where the pain is and what is causing it, while other areas integrate the sensory information with the total state of the organism and produce the emotional sensation called pain.

nursing interventions, the patient will be able to verbalize a total relief of pain AEB absence of pain, (−) facial grimaces, (−) guarding behavior, can totally move without experiencing pain, (−) cold clammy skin and (−) restlessness.

>Note non-verbal pain cues.

>Review factors.

>Analyze and document pain characteristics: precipitators, quality, region and radiation, severity, and time (frequency and duration).

>Non verbal cues may be both physiologic and psychological and may be used in conjunction with verbal cues to evaluate extent or severity of the problem.

>Helpful in establishing diagnosis and treatment needs.

>Careful analysis of pain characteristics aids in the differential diagnosis of pain. Systemic analysis prevents hasty and possibly inaccurate

absence of pain, (−) facial grimaces, (−) guarding behavior, can totally move without experiencing pain, (−) cold clammy skin and (−) restlessness.

>Work with the patient to identify the most effective ways to control pain.

>Eliminate additional stressors or source of discomfort like environmental factors whenever possible.

>Provide rest

conclusions about the quality or probable cause of pain. Standardized pain rating improves accuracy.

>Involving the patient in pain-control strategies promotes a sense of mastery that reduces fears of helplessness or loss of control.

>Patient may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are

periods to facilitate comfort, sleep, and relaxation.

>Provide comfort measures such as hot or cold compress.

>Explore various behavioral pain-control

further stressing her.

>Feeling well-rested increases tolerance of pain and the ability to cope with it. A quiet and clean environment is a measure geared towards facilitating rest.

>Hot, moist compress has a penetrating effect. The warmth rushes blood to the surrounding area to promote healing. A cold compress may reduce total edema and promote numbing, thereby promoting comfort.

strategies including relaxation techniques and distraction techniques.

>Encourage to have adequate fluid intake and of nutritious foods rich in vitamin C, iron and protein.>Administer and document analgesics as ordered.

>These techniques reduce muscle tension, enhance rest, and promote a sense of well-being by stimulating the relaxation response. Distraction is helpful for brief episodes of pain, but may increase pain perception and fatigue after the distracting stimulus is removed.

>Promotes faster wound healing.

>Nonnarcotic analgesics work

peripherally, inhibiting formation of prostaglandins and bradykinins. These are used to maintain acceptable level of pain.

PROBLEM #2: HYPERTHERMIA

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC EXPLAINATION

OBJECTIVES INTERVENTIONS

RATIONALE EXPECTED OUTCOME

S> Ø

O> the

patient

Hyperthermia

When the causative agent enters the body and invades the respiratory system, the inflammatory process is

Short term:After 4° of NI, the pt’s temperature will drop from 38.4 °C to 37 °C

1. Establish

Rapport

2. Monitor VS q

1. To gain trust and have a nurse patient relationship

2. To establish baseline data

Short term:

After 4° of NI,

the pt’s

temperature

shall drop

from 38.4 °C

manifested

>Flushed skin

>skin warm to

touch

>with body

temperature

of 38.4ºC

-The patient

may

manifest

>dehydration

>Irritability

triggered releasing platelets, WBC, RBC, which produces exudates of fibrin, which enhances the spread of microorganism, causing infection. In response to infection, the individual WBC release pyrogens. These pyrogens affect the body temperature- regulating mechanism in the hypothalamus of the brain. As a consequence, heat production and

Long term:

After 2-3 days of NI, the patient will be free from hyperthermia.

4°.

3. Provide TSB

as a measure.

4. Instruct SO

to provide with

loose clothing.

5. Assess skin

temperature

and color.

6. Monitor WBC

count.

of the pt’s

3. To lower pt’s temperature

4. To release heat and to provide comfort

5. Warm, dry,

flushed skin

may indicate a

fever.

6.Leucocytes

indicate an

inflammatory

to 37 °C.

Long term:

After 2-3 days of NI, the patient shall be free from hyperthermia.

conservation increase, a body temperature increases. Fever promotes activities of the immune system, such as phagocytosis, inhibits the growth of some microorganism.

7. Encourage

fluid intake

orally or

intravenously

as ordered.

8. Measure

intake and

output.

and infectious

process

presence.

7. Replaces

fluid lost by

insensible loss

and

perspiration.

8. Determine

fluid balance

and need to

increase fluid

intake.

Problem #3 ACTIVITY INTOLERANCE r/t generalize weakness

Assessment

Nursing Diagnosis

Scientific Explanation

Objectives Intervention RationaleExpected outcome

S: O:Patient may manifest>limited movement>report of pain and discomfort upon movement>inability to perform self-care activities

Activity Intolerance r/t generalize weakness

There is a limitation in independent, purposeful physical movement of the body or of one or more extremities due to weakness that the patient experiences brought about by decreased oxygen delivered to body tissues. This limits the patient’s

Short-term:After 4 hours of nursing interventions, the patient will be able to use identified techniques to enhance activity tolerance AEB decreased limited movement,

>Establish rapport.

>Assess, monitor and record vital signs.

>To facilitate health care intervention and promote participation and compliance to treatment regimen.

>To get baseline data and to note progress of patients condition.

The patient shall have identified techniques to enhance activity tolerance AEB decreased limited movement, and can perform self-care activities

>weakness>fatigue

mobility and is often exacerbated by movement leading to activity intolerance.

and can perform self-care activities with assistance.

Long-term:After 2 weeks of nursing interventions, the patient will be able to report a measurable increase in activity tolerance AEB absence of limited movement, and can perform self-care activities without assistance.

>Identify factors that could affect desired level of activity.

>Before activity, observe for and if possible treat pain.

> Instruct client in unfamiliar activities and in alternative ways of doing familiar activities.

> Assist client/SO(s) with planning for changes that may become necessary.

> Identify and discuss symptoms for which client needs to seek medical assistance/evaluatio

>To assess factors affecting current situation.

>Pain limits mobility and is often exacerbated by movement.

> To conserve energy and promote safety.

>To promote wellness.

> To provide for timely intervention.

> To sustain activity level.

with assistance.

Long-term:the patient shall have reported a measurable increase in activity tolerance AEB absence of limited movement, and can perform self-care activities without assistance.

n.

> Refer to appropriate sources for assistance and/or equipments as needed.

>Encourage to perform passive ROM exercises at least 2x a day.

>Provide adequate rest periods.

>Provide ample time to perform mobility-related tasks.

>Encourage to participate in self-

>Inactivity rapidly contributed to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of movement.

>To reduce fatigue.

>Limits fatigue, maximizing participation.

>Enhances self-concept and sense of independence.

care activities.

Problem# 4: RISK FOR INFECTION

Assessement

Nursing Diagnosi

s

Scientific Explanati

onObjectives Intervention Rationale Evaluation

S:O

O:Patient manifested:>(+) cold clammy skin> c low hemoglobin and hematocrit count>poor personal hygiene

Risk for spread of infection r/t inadequate secondary defenses as evidenced by low hematocrit and hemoglobin count.

Due to low count of hematocrit and hemoglobin and poor hygiene, risk for infection is greater. The skin, which is the body’s first line of defense, wherein

Short-term: After 4 hours of nursing interventions, the patient will be able to verbalize understanding of individual risk factors to prevent/reduce risk of infection AEB patient has demonstrated techniques/lifestyle changes to prevent/reduce

>Establish rapport.

>Assess, monitor and record vital signs.

>Note risk factors for occurrence of infection.

>To facilitate health care intervention and promote participation and compliance to treatment regimen.

>To get baseline data and to note progress of patients condition.

>To assess causative/contributing factors.

Short-term:the patient shall have verbalized understanding of individual risk factors to prevent/reduce risk of infection AEB patient has demonstrated techniques/lifestyle changes to prevent/reduce risk of infection by improving personal

Patient may manifest:>increased temperature>chills

whose natural defense mechanisms are inadequate to protect the patient from exposures that occur throughout the course of living. Risk for infection may occur when an organism invades a susceptible host.

risk of infection by improving personal hygiene, (−)cold clammy skin

Long-term: After 2 weeks of nursing interventions, the patient will be free from signs/symptoms of infection AEB maintenance of good personal hygiene, (−) cold clammy skin

>Stress proper handwashing techniques by all caregivers between therapies/clients.

> Monitor visitors/caregivers.

>Administer and monitor medication regimen and note the client’s response.

> Administer prophylactic antibiotic.

> Review individual nutritional needs and need for rest.

>Instruct client/SO(s) in techniques to prevent the

> A first-line defense against nosocomial infections.

>To prevent exposure of the client.

> To determine the effectiveness of therapy/presence of side-effects.

>To reduce/correct existing factors.

>To promote wellness.

>To promote wellness.

hygiene, (−)cold clammy skin

Long-term:the patient shall have been free from signs/symptoms of infection AEB maintenance of good personal hygiene, (−) cold clammy skin

spread/occurrence of infection.

Problem #5 RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS

CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONDESIRED

OUTCOMENURSING

INTERVENTIONSRATIONALE

EXPECTED OUTCOME

S: Ø O: The patient manifested:lack of appetiteinadequate intake of nutritious food>patient’s SO verbalization

Risk for imbalanced nutrition: less than body requirements

loss of appetite may also develop due to anemia, the demand for energy . Increase in the number of immature and ineffective lymphocytes will utilize the nutrients intended for

Short term: After 4 hrs of nursing interventions, the patient will demonstrate an increase in appetite AEB increased fluid and food intake.

Note patient’s daily total intake.

Auscultate bowel sounds. Observe/palpate for abnormalities distension.

Reveal changes that should be made in patient’s dietary intake.

Bowel sound may be diminished/ absent if the infection process is severe/ prolonged. Abdominal

Short term:the patient shall have demonstrated an increase in appetite AEB increased fluid and food intake.

Long term:the client shall have maintained optimal nutritious status AEB stabilized weight and increased fluid and

of a decrease in patient’s body weight rappears pale and weak

Patient may manifest:poor muscle tonecapillary fragility

the body’s needs, thus causing weight loss. Condition presented put the patient to the problem of risk for altered nutrition: less than body requirement related to anorexia.

Long term: After 1 week of nursing interventions, the client will maintain optimal nutritious status AEB stabilized weight and increased fluid and food intake.

Other than encouraging milk feeding, Provide small, frequent juices that are appealing to the patient.

Evaluate general nutritional state, obtain baseline weight.

Promote pleasant, relaxing environment.

distention may occur as a result of air swallowing or reflect the influence of bacterial toxins on the GI tract.

These measures may enhance intake even though appetite may be slow to return.

Presence of chronic condition or financial limitation can contribute to malnutrition, lowered resistance to infection, and/or delayed response to therapy.

To enhance intake by

food intake.

Prevent/minimize unpleasant odors/sights.

Limit activities.

Provide oral care before drinking and after coughing.

decreasing negative stimuli.

May have a negative effect on appetite.

Rest decreases metabolic needs. There are increased metabolic needs secondary to fever and infectious process.

Sputum can be foul tasting and decrease appetite.

Problem #6 : DISTURBED SLEEP PATTERN

CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONDESIRED

OUTCOMENURSING

INTERVENTIONSRATIONALE

EXPECTED OUTCOME

S: O: pt. may manifest:

>verbal complaints of difficulty falling asleep>restlessness>altered facial _expression (fatigued appearance)>verbal

Disturbed sleep pattern r/t environmental factors e.g. noise AEB verbalization of difficulty of sleeping.

Sleep is required to provide energy for physical and mental activities. The sleep-wake cycle is complex, consisting of different stages of consciousness. Disruption in the individual’s usual diurnal pattern of sleep and

SHORT TERM: After 3 hours of NI, patient will able to have adequate rest AEB verbalization of feeling rested, and improvement in sleep pattern.

LONG TERM:After 3 days

Establish rapport.

Assess, monitor vital signs.

Assess past patterns of sleep

To facilitate health care intervention and promote participation and compliance to treatment regimen.

To have a comparative/baseline data to note progress of condition.

To assess sleeping pattern and problems

SHORT TERM: The patient shall have had adequate rest AEB verbalization of feeling rested, and improvement in sleep pattern.

LONG TERM:The patient Shall have

complaints of not feeling rested>irritability>dozing>yawning>difficulty in arousal>change in activity level

wakefulness may be temporary or chronic. Such disruptions may result in both subjective distress and apparent impairment in functional activities. Sleep patterns can be affected by environment, especially in hospital critical care units.

of NI, patient will achieve optimal amounts of sleep AEB rested appearance, verbalization of feeling rested, and improvement in sleep pattern

in normal environment: amount, bedtime rituals, depth, length, positions, aids and interfering agents.

Identify factors that may facilitate or interfere with normal patterns.

Instruct patients to follow a consistent daily schedule for retiring and arising as possible.

Instruct to avoid heavy meals, alcohol, caffeine, or smoking before retiring.

Instruct to avoid large fluid intake before bedtime.

encountered by the patient

To identify appropriate nursing interventions

To facilitate sleeping patterns

This can alter in promoting sleep

To avoid in between waking at night and promote rest and sleep

achieved optimal amounts of sleep AEB rested appearance, verbalization of feeling rested, and improvement in sleep pattern