ncp presentation

24
DATE CUES NEED NURSING DIAGNOSIS OBJECTIVES OF CARE INTERVENTIONS EVALUATION J U L Y 0 5 2 0 1 0 @ 3:00 PM S: “dli mn gud ko gnhan muinom pro kung mukaon ko, muinom ko pra diretso tulon pro dli pud kaau dghan” O: Decrease fluid intake Acute weight loss Decrease skin turgor N U T R I T I O N A L - M E T A B O L I C P A T Fluid volume deficit related to inadequate fluid intake Rationale: Fluid volume disturbances results from loss of body fluids and occurs more rapidly when coupled with decrease fluid intake. Causes of FVD include abnormal fluid losses, decreased intake and third-space fluid shifts. The therapeutic goal is to treat After 2 days span of nursing care, my patient will be able to: a) Maintain fluid volume at a functional level as evidenced by individually adequate urinary output, stable vital signs, moist mucous membranes, and good skin turgor; b) Verbalize understandin g of 1. Establish rapport. ® To elicit patient’s trust and cooperation. 2. Determine effects of age. ® Very young and extremely elderly individuals are quickly affected by fluid volume deficit, and are least able to express need. For example, elderly people often have a decreased thirst reflex and/or may not be aware of water needs. 3. Monitor and document vital signs. ® Sinus tachycardia may occur with hypovolemia to maintain an July 06, 2010 “GOAL PARTIALLY MET” After the 2 days span of nursing care, my patient was: a) Able to maintai n fluid volume at a functio nal level as evidenc e by individ ually adequat

Upload: z4oxal

Post on 10-Apr-2015

929 views

Category:

Documents


3 download

TRANSCRIPT

Page 1: Ncp Presentation

DATE CUES NEED NURSING DIAGNOSIS

OBJECTIVES OF CARE

INTERVENTIONS EVALUATION

JULY

05

2010

@

3:00PM

S: “dli mn gud ko gnhan muinom pro kung mukaon ko, muinom ko pra diretso tulon pro dli pud kaau dghan”

O:Decrease fluid

intake Acute weight

lossDecrease skin

turgorWeaknessDry mucous

membraneSunken eyesThirst but

refuses to drink

Output greater than intake

Increase pulse

NUTRITIONAL-METABOLIC

PATTERN

Fluid volume deficit related to inadequate fluid intake

Rationale:Fluid volume disturbances results from loss of body fluids and occurs more rapidly when coupled with decrease fluid intake. Causes of FVD include abnormal fluid losses, decreased intake and third-space fluid shifts. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal.

After 2 days span of nursing care, my patient will be able to:

a) Maintain fluid volume at a functional level as evidenced by individually adequate urinary output, stable vital signs, moist mucous membranes, and good skin turgor;

b) Verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications; and

c) Demonstrate behaviors to

1. Establish rapport.® To elicit patient’s trust and cooperation.2. Determine effects of

age.® Very young and extremely elderly individuals are quickly affected by fluid volume deficit, and are least able to express need. For example, elderly people often have a decreased thirst reflex and/or may not be aware of water needs.3. Monitor and document

vital signs.® Sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output. Usually the pulse is weak and may be irregular if electrolyte imbalance also occurs. 4. Note change in usual

mentation/behavior/functional abilities.

® These signs indicate sufficient dehydration to cause poor cerebral

July 06, 2010

“GOAL PARTIALLY

MET”

After the 2 days span of nursing care, my patient

was:a) Able to

maintain fluid volume at a functional level as evidence by individually adequate urinary output (from 2020ml to 1020ml) but wasn’t able to

Page 2: Ncp Presentation

rate and heart rate

monitor and correct deficit, as indicated, when condition is chronic.

perfusion and/or electrolyte imbalance.5. Encourage the patient

to drink prescribed fluid amounts:

Place fluids at bedside within easy reach

Provide fresh water and straw

® oral fluid replacement is indicated for mild fluid deficit and is a cost-effective method for replacement treatment. Older patients have a decreased sense of thirst and may need ongoing reminders to drink.6. Administer fluids and

electrolytes, as indicated.

® Fluids used for replacement depend on 1.) the type of dehydration present (hypertonic/hypotonic), and 2.) the degree of deficit determined by age, weight, and type of condition causing the deficit.7. Establish 24-hour

attain stable vital signs (RR-22cpm), dry mucous membrane and poor skin turgor.

b) Not able to verbalize understanding causative factors and purpose of individual therapeutic interventions and medications

c) Able to demonstrate behaviors

Page 3: Ncp Presentation

replacement needs and routes to be used (e.g., IV).

® Steady rehydration over time prevents peaks/valleys in fluid level.8. Provide oral hygiene.® Attention to mouth care promotes interest in drinking.9. Limit intake of

alcohol/caffeinated beverages.

® It tends to exert a diuretic effect.10.Provide frequent oral

and eye care.® To prevent injury from dryness.11.Discuss factors related

to occurrence of deficit, as individually appropriate.

® Early identification of risk factors can decrease occurrence and severity of complications associated with hypovolemia.

to monitor and correct deficit, as indicated, when condition is chronic such as a slight increase in oral fluid intake and decrease in urine output.

Page 4: Ncp Presentation

DATE CUES NEED NURSING DIAGNOSIS

OBJECTIVES OF CARE

INTERVENTIONS EVALUATION

JULY

05

2010

@

3:00PM

Subjective:

“Malipong-lipong man ko kung magbangon ko ug dli ko kadugay kung magbangon ko”

Objective:

Generalized weakness;

CBR without BRP;

Side effects of medications

ACTIVITY-EXERCISE

PATTERN

Activity Intolerance related to weakness secondary to exploratory laparotomy

® Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in older patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary-related problems. The aging process itself causes reduction in muscle strength and functions, which can impair the ability to maintain activity. Activity intolerance

After 2 days span of nursing care, my patient will be able to:

d) Demonstrate a stable in physiological signs of intolerance as evidence by a stable vital signs;

e) Use identified techniques to enhance desired activity; and

f) Verbalizes and uses energy conservation

1. Establish guidelines and goals of activity with the patient and care giver®Motivation is enhanced if the patient participates in goal setting. Depending on the etiological factors of the activity intolerance, some patients may be able to live independently and work outside the home. Other patients with chronic debilitating disease may remain homebound.

2. Refrain from performing procedures.®Patients with limited activity tolerance need to prioritize tasks.

3. Progress activity

July 06, 2010“GOAL

PARTIALLY MET”

After the 2 days span of nursing care, my patient

was:d) Able to

demonstrate stable vitals signs:BP: 110/60Temp: 37.3RR: 20PR: 89CR:90

b.)not able to used identified techniques to enhanced desired activity;c.) not able to verbalize

Page 5: Ncp Presentation

may also be related to factors such as obesity, malnourishment, anemia, side effects of medications (e.g., Beta-blockers), or emotional states such as depression or lack of confidence to exert oneself. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient maintain a satisfactory quality of life.

gradually, as with the following:a.) Dangling legs

10-15 minutes three times daily;

b.) Deep breathing exercises three or more daily®This prevents overexerting the heart and promotes attainment of short-range goals.

4. Promote emotional support while increasing activity. Promote a positive attitude regarding activities.®patient may be fearful of overexertion and potential damage to the heart. Appropriate supervision during early efforts can enhance confidence.

5. Teach the patient

and uses energy conservation.

Page 6: Ncp Presentation

and caregiver to recognize signs of physical over activity.®this promotes awareness of when to reduce activity.

6. Teach energy conservation techniques, such as the following: ®these reduce oxygen consumption, allowing more prolonged activity.

a.) Sitting to do tasks® standing requires more work.

b.) Changing positions often.®this distributes work to different muscle

7. Teach appropriate use of environmental aids (e.g., bed rails, elevating head of bed while patient

Page 7: Ncp Presentation

gets out the bed, chair in the bathroom).® these conserve energy and prevent injury from fall.

Page 8: Ncp Presentation

DATE CUES NEED NURSING DIAGNOSIS

OBJECTIVES OF CARE

INTERVENTIONS EVALUATION

JULY

7,

2010

@

3PM

S>The patient verbalized, “Agay!sakit. Sakit gihapon akong tinahian.”>”Ayaw lang hilabti sa akong tiyan banda kay sakit.”

O>vertical incision below the sternum bypassing the umbilicus up to 2 inches below the umbilicus >guarding of abdominal area>changes position slowly to avoid pain>irritable>changes in vital sign especially the cardiac rate

COGNITIVE-PERCEPTION

PATTERN

Acute pain related to tissue injury secondary to exploratory laparotomy

®Pain is an unpleasant and highly personal experience that may be imperceptible to others, while consuming all parts of the person’s life. It is usually a response to actual tissue damage, so there may not be abnormal laboratory or radiographic reports despite real pain.

At the end of my 8 hours span of care, my patient will be able to:

a. report pain is controlled;

b. follow prescribed pharmacological regimen; and

verbalize nonpharmaco-logic methods that provide relief.

1. Note location of surgical incision.®this can influence the amount of postoperative pain experienced.

2. Note client’s locus of control.®individuals with external locus of control may take little or no responsibility for pain management.

3. Accept the client’s description of pain.®pain is a subjective experience and cannot be felt by others.

4. Observe non-verbal cues/pain behaviors.®observation may/may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize.

5. Monitor skin color/temperature and vital signs.®these are usually

July 7, 2010@

11 pm“GOAL

PARTIALLY MET”

At the end of my 8 hours span of care, my patient was:

a. unable to report control of pain;

b. able to take all due oral medications for pain or analgesics; and,

able to verbalize, “dapat mag deep breathing para dili mulala ang sakit sa akong samd.”

Page 9: Ncp Presentation

and pulse rate>sighing>grimaced face>analgesic medications>Pain scale of 7 out of 10

altered in acute pain.6. Determine client’s

acceptable level of pain/pain control levels.®it varies with the individual and situation.

7. Note when pain occurs.®to medicate prophylactically, as appropriate.

8. Provide comfort measures, and quiet environment.®to promote nonpharmacological pain management.

9. Instruct in/encourage use of relaxation techniques such as focused deep breathing.®to distract attention and reduce tension.

10.Administer analgesics as ordered.®to maintain acceptable level of pain. Notify physician if regimen inadequate to meet pain control goal.

Page 10: Ncp Presentation

11.Encourage adequate rest periods.

®to prevent fatigue.

Page 11: Ncp Presentation

DATE CUES NEED NURSING DIAGNOSIS

OBJECTIVES OF CARE

INTERVENTIONS EVALUATION

JULY

5,

2010

@

3 pm

Subjective :

Head eache

Verbalized:” init man akung lawas”

Temperature of 38.4oC

Skin is warm to touch

N

U

T

R

I

T

I

O

N

A

L

M

E

T

A

L

Hyperthermia related to increase metabolic rate secondary to hyperthyroidism

Rationale:Patient with hyperthyroidism frequently finds a normal room temperature too warm because of an exaggerated metabolic rate and increased heat production.

At the end of my eight hour care, the patient will:

Maintain core temperature within normal range.

Be free of complication such as irreversible brain/ neurological damage

Inentify underlying cause/ contributing factors and importance of treatment, as well as signs/ symptoms requiring further

Tepid sponge bath rendered®independent nursing action should be done first to subside the fever of the patient before dependent nursing action.

Re check the temperatute after 15-30 min.Rto determine if the procedure is effective in lowering the temperature

Administer anti-pyretic drugs if intervention is ineffective per doctor’s orderRto avoid condition from exacerbating

Check patient’s chart Rto note if there are other contributory factors of hyperthermia

Monitor vital signs

07-05-10

11:00 PM

“GOAL PARTIALLY

MET”

After my eight hour care the patient had maintain his temperature within normal range: 37.1oC

He demonstrated no signs of complications such as: irreversible brain damage

Patient

Page 12: Ncp Presentation

M

E

T

A

B

O

L

I

C

P

A

T

T

E

R

N

evaluation or intervention.

Demonstrate behavior to monitor and promote normothermia.

Be free from seizures activity.

Rto know if there are sudden changes in vital signs wich may indicate signs of infection

Check hydration status of clientRhyperthermia may precipitate dehydration

Monitor/ record all source of fluid loss such as urine(

Roligouria and/ or renal failure may occur due to hypotention, dehydration, shock, and tissue necrosis);vomiting and diarrhea; wounds/ fistulas; and insensible losses(R potential fluid and electrolyte losses )

Note presence/ absence of sweating as body attemps to increase heat loss by evaporation, conduction, and diffusion.

was unable to increase OFI because of vomiting

The client did not have seizures or signs that may lead to seizuresSuch as:

a) Increase in BP

b) Increase temperature

c) Spasmic attract

VS: a) PR:

93bpmb) CR:

95bpmc) RR:

20cpmd) BP:

110/60

Page 13: Ncp Presentation

R evaporation is decreased by environmental factors such as humidity and high ambient temperature, as well as body factors of high ambient temperature, as well as body factors producing loss of ability to sweat or sweat or sweat glands dysfunction

Monitor intake and outputRto replace loss fluid from diaphoresis.

e) Temp.: 37.1

Page 14: Ncp Presentation

DATE CUES NEED NURSING DIAGNOSIS

OBJECTIVES OF CARE

INTERVENTIONS EVALUATION

JULY

05

2010

@

3:00PM

S: “dili man gud ko ganahan muinom pero kung mukaon ko, muinom ko pra diretso tulon pero dli pud kaayu daghan” as verbalized by patient

O: Stomati

tis on the right buccal mucosa

White patches at both right and left buccal

Dry mouth

Cracke

NUTRITIONAL-METABOLIC

PATTERN

Impaired Oral Mucous Membrane r/t Dehydration

®Minor irritation of the mucous membrane occasionally occurs to any person. Dehydration can cause impaired oral mucous membrane because of the decrease moisture of the area. Since lubrication is not present, it can cause irritation.

After 2 days span of nursing care, my patient will be able to:

1.) Have an intact oral mucosa as evidenced by:a. Clean

oral cavity

b. Free from lesions and stomatitis

2.) Demonstrate appropriate oral hygiene

3.) Verbalize relief from stomatitis

1. Assess status of oral mucosa; include tongue, lips, mucous membranes, gums, saliva, and teeth.®These are frequent sites for infection and irritation. Patient or home caregivers also need to be informed of the importance of these assessments.

2. Determine nutrition/fluid intake and reported changes like avoiding eating and changes in taste.®Indicates problems with oral mucosa

3. Assess medication use and possibility of side effects.®Affects health or integrity of oral mucous membranes.

4. Evaluate client’s ability to provide self-care

July 06, 2010“GOAL

PARTIALLY MET”

After the 2 days span of nursing care, my patient

was:

1. Oral cavity was clean but stomatitis and lesions are still present.

2. Able to do indipendent appropriate oral hygiene

3. Stomatitis was not relieved.

Page 15: Ncp Presentation

d lips Freque

nt use of CB with water to be wiped in the patient’s lips and tongue

Small amount of fluid intake

Acute weight loss

Poor skin turgor

Weakness

Sunken eyes

Thirst but refuses to drink

Output greater

and availability of necessary equipment/assistance.®client’’s current health affects ability to provide care.

5. Encourage to have adequate fluids.®To prevent dry mouth and dehydration.

6. Encourage to have citrus foods and drinks, chewing gum, or hard candy.

®To stimulate saliva

7. Encourage gentle gum massage and tongue brushing with soft toothbrush or sponge/cotton tip applicators.®limits mucosal/gum irritation.

8. Encourage to have saline rinse or diluted alcohol-free mouthwashes.®To kill the bacteria present in the oral

Page 16: Ncp Presentation

than intake

Increase pulse rate and heart rate

mucosa.

9. Provide nutritional information.®To correct deficiencies, reduce irritation/gum disease, prevent dental caries.

10.