ncp

NURSING CARE PLANPROBLEM: Ineffective breathingNURSING DIAGNOSIS: Ineffective breathing pattern r/t pain as evidenced by hypoventilation and increased in respiratory rateTAXONOMY: Activity-Exercise patternCAUSE ANALYSIS: Pain can lead to anxiety and secondary to reflex musculoskeletal spasm, which in turn tend to worsen pain. Inadequate treated pain can provoke physiologic responses that can alter circulation and tissue metabolism and produce a physical manifestation, such as tachycardia, reflective of increased sympathetic activity. ( Carol Mattso, Porth “Pathophysiology” concepts of altered health status, 6th edition, p. 1130)

CUES OBJECTIVES INTERVENTION RATIONALE EXPECTED OUTCOME

SUBJECTIVE:

OBJECTIVES>Respiratory rate above normal range >hypoventilation

STO: After 8 hours of giving care

and interventions, patient will be able to demonstrate breathing pattern that supports blood gas results with in clients normal parameters

LTO: After 3 days of giving care

and with appropriate nursing intervention patient will be able to maintain an effective breathing as evidence by:

- normal rate, rhythm & depth of respiration

-absence of hypoventilation

Independent

Monitor RR, depth, ease of respiration

Note pattern of respiration

Monitor the presence of pain and provide pain medication for comfort as needed

Position client in an upright or semi-fowler’s position with lateral position for 60-90 minutes.

Encourage client to take deep breaths at prescribe interval or use of incentive spirometer; reinforce client’s progress

In acute dyspneic state, ensure that the client has received the medications or treatment needed and then stay to provide support.

Normal reparatory rate is 12-16 bpm in adult

Normal respiratory pattern is regular in the healthy adult

Pain causes the client to hypoventilate avoid taking deep breath

It facilitates lung full expansion

Anxiety can exacerbate dyspneic panic state. The nurse presence, reassurance, and help in controlling the client’s breathing with slower pursed-lip breathing is helpful

STO: After 8 hours of giving care and

interventions, patient was able to demonstrate breathing pattern that supports blood gas results with in clients normal parameters

LTO: After 3 days of giving care

and with appropriate nursing intervention patient was able to maintain an effective breathing as evidence by:

- normal rate, rhythm & depth of respiration

-absence of hypoventilation

references: NCP 6th edition by: Doenges Nurses Pocket Guide 7th edition by: Doenges

PROBLEM: feverNURSING DIAGNOSIS: hyperthermia r/t effect of endogenous pyrogens TAXONOMY: Nutritional-metabolic patternCAUSE ANALYSIS: endogenous pyrogens (interleukin-1) which comes from macrophages and activated by phagocytosis, endotoxins and others act on the temperature regulating centers in the hypothalamus to elevate the thermostat set-point by inducing the hypothalamus to release prostaglandin E3, which acts on the hypothalamus to evoke fever response. When the set-point is increased, mechanism for raising body temperature is activated. (Focus on pathophysiology by Bullock and Henzie, pp. 264)


SUBJECTIVES:>patient may verbalized chilling sensation with associate periods of warm or flushed skin

OBJECTIVES> increase temperature above normal range> increase RR,>20 bpm>skin warm to touchskin that appears flushed and feels warm (fever abatement)>glassy-eyed appearance

STO: After 2-3 days in giving nursing intervention, the patient will be able to decrease its temperature by 0.50 C- 10 C until it reaches to normal range.

LTO: After 10 days of giving nursing intervention, the patient will be able to maintain core temperature within normal range.

INDEPENDENT:>monitor temperature (degree &pattern); note chills/ profuse diaphoresis

>provide TSB; avoid use of alcohol

>note presence/ absence of sweating as body attempts to increase heat loss by evaporation, conduction, and diffusion.

>assess neurologic response, noting level of consciousness and orientation; reaction to stimuli; reaction of pupils and presence of posturing seizures

>provide cooling blankets

COLLABORATIVE:>administer antipyretics (Tylenol, paracetamol)

>temperature of 102o F – 106o F (38.9o C- 41.10 C) suggests acute infection disease process. Chills often precede temp. Spikes.

>may help reduce fever

>evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat

>neurologic conditions of an individual may be affected if there’s an increase in temperature

>helps to reduce fever

>it reduces fever by its central action on the hypothalamus

STO: After 2-3 days in giving nursing intervention, the patient was able to decrease its temperature by 0.50 C- 10

C until it reaches to normal range.

LTO: After 10 days of giving nursing intervention, the patient was able to her/his maintain core temperature within normal range.

References: NCP 6th edition by: Doenges Nurses Pocket Guide 7th edition by: Doenges

PROBLEM: Fatigue NURSING DIAGNOSIS: Fatigue r/t severe pain as evidenced by yawning, irritability, and rapid pulseTAXONOMY: Activity-Intolerance Pattern CAUSE ANALYSIS: The severe pain of biliary colic is produced by obstruction of the cystic duct of the gallbladder. When a store is moving through or is lodged within the n an effort to mobilize the stone through the small duct. This intense pain may be so sever that it is accompanied by tachycardia, pallor, diaphoresis, and prostration (extreme exhaustion). (Medical-Surgical Nursing 5th edition by Ignativicius p.1399)


SUBJECTIVE:>The patient may verbalize complaints of being tired and inability to maintain usual routines.

P- following ingestion of fatty foods, alcohol or caffeine/after mealsQ- sharp pain or excruciating pain.R- RUQ that may radiate to right or left scapula.S- severe ( may report 8-10)T- onset: sudden, lasting 2-4 hours

OBJECTIVES>yawning>irritability >dark shadows under the eye>uncoordinated movements>lethargic>inability to concentrate>shortness of breath>rapid pulse(>100bpm)

STO: After 2-3 days in giving nursing intervention, the patient will be able to verbalize a measurable increase in activity tolerance.

LTO: After 10 days of giving nursing intervention, the patient will be able to have responsibility to self and to demonstrate progressiveActivity as tolerated and utilizes (activity) energy saving techniques.

INDEPENDENT>Monitor the client for evidence of excess physical and emotional fatigue.

>Monitor nutritional intake.

> Reduce physical discomforts.

> Arrange Physical activities (e.g., avoid activity immediately after meals).

> Encourage alternate rest and activity periods.

>Assist the client to schedule rest periods and avoid care activities during scheduled rest periods.

> Instruct the client or significant other to recognize the signs and symptoms of fatigue.

COLLABORATIVE>Collaborate with the client/family and the rehabilitation team.

>Extended periods of inactivity may place the client at risk for excessive fatigue when carrying out desired activities.

> Monitoring nutritional intake ensures that the client has adequate energy resources.

> Physical discomforts could interfere with cognitive function and self-monitoring/regulation of activity.

>Arranging physical activities reduces competition for oxygen supply to vital body functions.

>This avoids extended periods of either activity or exercise.

> Rest periods should help restore client energy levels.

> Symptoms of undue fatigue require a reduction in activity.

>Effective interdisciplinary interventions facilitate the client’s ability to manage his or her life.

After giving nursing intervention the patient was able to denies fatigue; no verbal report or observation of being lethargic or listless; denies feeling tired; denies an increased in rest requirements and no verbal report and observation of lack of energy.

References: NCP 6th edition by: Doenges Medical-Surgical Nursing 5th edition by Ignativicius p.138

Problem: Inability to fall asleepNursing Diagnosis: Sleep pattern disturbance related to pain secondary to CholelithiasisGordon’s: Sleep-Rest PatternCause Analysis: This problem can occur when an individual felt pain or sensation of pressure in the epigastrium or right upper quadrant, which may radiate to the right scapular area or right Shoulder. (Ref. Lippincott’s Pocket Manual of Nursing Practice pg. 198)

CUES OBJECTIVES INTERVENTIONS RATIONALE Expected outcome

Subjective:

Patient may report “di ko katulog tungod sa sakit nga aking gakabati”.


STO: Within 8 hours of giving

appropriate nursing care, pt. will have less uninterrupted asleep and decreased pain as evidenced by a sleeping 5-6 hours with a pain scale of 3-4/10

LTO Within 3 days of care, the

patient’s pain/discomfort will be totally diminished and patient will report of sleep period of 6-8 hours

Independent Assess client’s sleep patterns and

usual bedtime rituals and incorporate these into the plan of care

Observe client’s meds, diet and caffeine intake

Provide measure to assist with sleep

Keep environment quite

Inform client of the normal changes in sleep pattern that occur with aging

Discourage intake of foods and fluids high in caffeine (chocolate, coffee, tea) especially in the night

Collaborative: Administer analgesic as

Usual sleep patterns are individual, data colleted through a comprehensive and holistic assessment are needed to achieve the etiology of the disturbance

Difficulty sleeping can be a side effects of meds given, caffeine intake can interfere with sleep.

Noise can increase sleep deprivation.

Critical care nurses can take effective action to promote sleep

In order to reduce concerns about quantity of sleep necessary to maintain health

This can promote excessive urination which may hinder proper night rest.

STO: After 8 hours of giving

appropriate nursing care, pt had less uninterrupted asleep and decreased pain as evidenced by a sleeping 5-6 hours with a pain scale of 3-4/10

LTO after 3 days of care, the

patient’s pain/discomfort was totally diminished and patient will report of sleep period of 6-8 hours

Objectives: Fatigue Facial grimace Guarded

movement Irritability

ordered and evaluate effectiveness

Give Meperidine as indicated

Administering analgesia to an individual helps to control pain

Provides temporary relief of pain, enhances pt’s ability to cope with situation.

Reference: Gulanick, et.al. Nursing Care Plans, Nursing Diagnosis and Intervention 3rd edition

PROBLEM: Pain NURSING DIAGNOSIS: Altered comfortt related to obstruction/ductal spasm secondary to choleliliatiasis. TAXONOMY: Cognitive-Perceptual PatternCAUSE ANALYSIS: If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute cholecystitis). The patient may have biliary colic with excruciating upper abdominal pain that radiates to the back or shoulder. Such a bout of biliary colic is caused by contraction of the gallbladder, which release bile because of obstruction by the stone.

CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOMES

SUBJECTIVE:


OBJECTIVE:Reports of pain

STO:After 8 hours of giving nursing intervention, the patient will be able to demonstrate use of relaxation skills and diversional activities as indicated for individual situation

LTO:After 2-3 days of initiating effective nursing intervention, the patient will be able to demonstrate comfort as evidenced by movement without grimacing, by requesting

INDEPENDENT:.Observe and document location, severity (0-10 scale), and character of pain

Promote bedrest, allowing patient to assume position of comfort.

Encourage expression of feelings about pain.

Use soft/ cotton linens; calamine lotion, oil (Alpha Keri) bath; cool/

Assists in differentiating cause of pain, and provides information about disease progression/ resolution, development of complications, and effectiveness of interventions.

Bed rest in low-Fowler’s position reduces intra-abdominal pressure; however, patient will naturally assume least painful position.

Verbalization allows outlet for emotions and may enhance coping mechanisms.

Reduces irritation/ dryness of the skin and itching sensation.

After 8 hours of giving nursing intervention, the patient was able to demonstrate use of relaxation skills and diversional activities as indicated for individual situation

After 2-3 days of initiating effective nursing intervention, the patient was able to

Facial grimaceChanges in BP and pulse DiaphoresisGuarding behavior

analgesics no more frequently than ordered and by statement that the pain is tolerable and not interfering with rest or physical therapy.

moist compresses as indicated.

Encourage use of relaxation techniques, e.g., guided imagery, visualization, deep-breathing exercises. Provide diversional activities.

Make time to listen to and maintain frequent contact with patient.

Promotes rest, redirects attention, may enhance coping.

Helpful in alleviating anxiety and refocusing attention, which can relieve pain.

demonstrate comfort as evidenced by movement without grimacing, by requesting analgesics no more frequently than ordered and by statement that the pain is tolerable and not interfering with rest or physical therapy.

Referrence: Kozier, et. al .Fundamentals of Nursing, 5th edition. Doenges, et. al. Nursing Care Plans, 6th edition.

Problem: ItchingNursing Diagnosis: Risk for impaired skin integrity related to pruritus secondary to obstructive jaundice.Taxonomy: Nutritional-Metabolic Pattern Cause Analysis: In a person with obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excessive bile salts to accumulate in the skin. This accumulation of bile salts leads to pruritus (itching) or a burning sensation. (Medical-Surgical Nursing by Ignativicius p. 1397). This predisposes the individual to impaired skin integrity.CUES OBJECTIVES I NTERVENTIONS RATIONALE EXPECTED OUTCOMESUBJECTIVE: The client may verbalized itching both in upper and lower extremities.

OBJECTIVES: *yellowish, itchy skin *scratching *restlessness *irritability

STO:After 30 minutes of effective health teaching, the patient will be able to verbalized understanding as evidenced by scratching episodes and increased comfort.

LTO:Within 3 days of effective nursing intervention, the patient will be able to maintain clean, moist skin, free from scratching and the patient

1) Health Teachings:a) Advise the client not to take hot baths.b) Advise the client against scratching.c) Explain the cause of itching.d) Avoid clothing that continuously rubs the skin such as tight belts, nylon stockings and panty hose.e) Do not apply rubbing alcohol, astringents or other agents.f) Avoid caffeine and alcohol ingestion.g) Encourage client to keep the

-hot baths stimulates itching.

-it stimulates itching and increases risk for infection.

-for clients further understanding.-(this are guidelines to prevent dryness of the skin)-to prevent dry skin

After 30 minutes of effective health teaching, the patient was able to verbalized understanding as evidenced scratching episodes and increased comfort.

Within 3 days of effective nursing intervention, the patient was able to maintain clean, moist skin, free from scratching and the patient verbalizes increased comfort.

verbalizes increased comfort. fingernails trimmed short, with rough edges filed.h) Tell the clients to wear mitters or splints at night.

2) Keep bedclothes dry, use nonirritating materials, and keep bed free from wrinkles, crumbs, and so forth.

3) Therapeutic baths (balneotherapy) with colloidal oatmeal preparations or tar extracts.

4) Suggest use of ice, colloidal bath, lotions.

COLLABORATIVE:

1) Give antihistamine as prescribed and closely monitor the client’s response to therapy.

-to reduce skin damage

-it can help to prevent inadvented scratching during sleep.

-this may give temporary relief.

-to decrease irritable itching.

May reduce itching. The client’s response should be closely monitored so that dosages can be adjusted as needed.

References: Nurse’s Pocket Guide 10th edition by Doenges pp. 492-495 Nursing Diagnosis and Intervention by Campbell pp.922-923 Medical Surgical Nursing 5th edition by Ignativicius p. 1576

Problem: Risk for fluid volume deficitNursing Diagnosis Risk fpr fluid volume deficit related to excessive losses through gastric suction; vomiting, distension, and gastric hypermotilityGordon’s: Nutritional metabolic pattern

Cause Analysis:


Subjective:The patient may verbalize “excessive vomiting”

Objectives:

V/ST-BP-P-Dry skinDry mucous membranePoor skin turgorDecrease urine output (500mlper day)Vomiting

STO: After 8 hours of giving effective nursing interventions, the patient will be able to display positive response regarding health teachings.

LTO: After 3 days of giving effective nursing interventions, the patient will be able to demonstrate adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output and absence of vomiting.

IndependentMaintain accurate record of I&O, noting output less than intake, increased urine specific gravity. Assess skin/mucous membranes, peripheral pulses, and capillary refill.

Monitor for signs/symptoms of increased/continued nausea or vomiting, abdominal cramps, weakness, twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, depressed respirations.

Eliminate noxious sights/smells from environment.

Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.

Use small-gauge needles for injections and apply firm pressure for longer than usual after venipuncture.

Collaborative

Keep patient NPO as necessary.

Insert NG tube, connect to suction, and maintain patency as indicated.

Administer antiemetics, e.g., prochlorperazine (Compazine).

Review laboratory studies, e.g., Hb/Hct, electrolytes, ABGs (pH), clotting times.

ADMINISTER IV FLUIDS, ELECTROLYTES, AND VITAMIN K.

Provides information about fluid status/circulating volume and replacement needs.

Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride.

Reduces stimulation of vomiting center.

Decreases dryness of oral mucous membranes; reducesrisk of oral bleeding.

Reduces trauma, risk of bleeding/hematoma formation

Decreases GI secretions and motility.

Provides rest for GI tract.

Reduces nausea and prevents vomiting.

Aids in evaluating circulating volume, identifies deficits, and influences choice of intervention for replacement/correction.

MAINTAINS CIRCULATING VOLUME AND CORRECTS IMBALANCES.

STO After 8 hours of giving effective nursing interventions, the patient was able to display positive response regarding health teachings.

LTO: : After 3 days of giving effective nursing interventions, the patient was able to demonstrate adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output and absence of vomiting

Reference: Gulanick, et.al. Nursing Care Plans, Nursing Diagnosis and Intervention 3rd edition Davis, E.A. Nursing Care Plans

Problem: Knowledge deficitNursing Diagnosis Knowledge deficit related to unfamiliarity with information resourcesGordon’s: Cognitive-Perceptual PatternCause Analysis: The total range of what has been learned or perceived as true is knowledge. It is accumulated through experience, study, or investigation. Culture, socio-economic factors, age affects knowledge or perception (p39, General Sociology Focus on the Philippines 3rd Ed. by Panopio, Raymundo, Cordero-MacDonald)


Subjective:

Objectives:

Questions; request for information

Statement of misconception

Inaccurate follow-through of instruction

Development of preventable complications

STO: After 8 hours of giving effective nursing interventions, the patient will be able to verbalize understanding about his condition and enumerate the factors that aggravate the condition.

LTO: After 8 hours of giving effective nursing interventions, the patient would correctly perform necessary procedures and explain reasons of actions demonstrate/initiate necessary lifestyle changes and participate in treatment regimen.

IndependentProvide explanations of/reasons for test procedures and preparation needed.

Review disease process/prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern.

Review drug regimen, possible side effects.

Discuss weight reduction programs if indicated

Instruct patient to avoid food/fluids high in fats (e.g., whole milk, ice

. Information can decrease anxiety, thereby reducing sympathetic stimulation.

Provides knowledge base from which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing.

Gallstones often recur, necessitating long-term therapy. Development of diarrhea/cramps during chenodiol therapy may be dose-related/correctable. Note: Women of childbearing age should be counseled regarding birth control to prevent pregnancy and risk of fetal hepatic damage.

Obesity is a risk factor associated with cholecystitis, and weight loss is beneficial in medical management of chronic condition.

Prevents/limits recurrence of gallbladder

STO After 8 hours of giving effective nursing interventions, the patient will be able to to verbalize understanding about his condition and enumerate the factors that aggravate the condition.

LTO: After 3 days of giving effective nursing interventions, the patient will be able to

cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans, onions, carbonated beverages), or gastric irritants (e.g., spicy foods, caffeine, citrus).

attacks.LTO: After 8 hours of giving effective nursing interventi would correctly perform necessary procedures and explain reasons of actions demonstrate/initiate necessary lifestyle changes and participate in treatment regimen. ons, the patient will be able to

Reference: Gulanick, et.al. Nursing Care Plans,

Problem: Lack of appetite

Nursing Diagnosis: Altered nutrition less than body requirements related to self-imposed o r prescribed dietary restrictions, nausea/vomiting, dyspepsia, pain Gordon’s: Nutritonal metabolic patternCause Analysis:


Subjective:

The patient may verbalize “excessive vomiting” and pain.

P- following ingestion of fatty foods, alcohol or caffeine/after mealsQ- sharp pain or excruciating pain.R- RUQ that may radiate to right or left

STO: After 8 hours of giving effective nursing interventions, the patient will be able to report relief of nausea/vomiting.

LTO: After 3 days of giving effective nursing interventions, the patient will

IndependentEstimate/calculate caloric intake. Keep comments about appetite to a minimum.

Weigh as indicated.

Consult with patient about likes/dislikes, foods that cause distress, and preferred meal schedule.

Provide a pleasant atmosphere at mealtime; remove noxious stimuli.

Provide oral hygiene before meals.

Identifies nutritional deficiencies/needs. Focusing on problem creates a negative atmosphere and may interfere with intake.

Monitors effectiveness of dietary plan.

Involving patient in planning enables patient to have a sense of control and encourages eating.

Useful in promoting appetite/reducing nausea.

STO

After 8 hours of giving effective nursing interventions, the patient was able to report relief of nausea/vomiting, and pain.

scapula.S- severe ( may report 8-10)T- onset: sudden, lasting 2-4 hours

Objectives:

-Dry skin-Dry mucous membrane-Poor skin turgor -Vomiting-anorexia-wt. loss

be able to demonstrate progression toward desired weight gain or maintain weight as evidenced by the absence of nausea/vomiting.

Offer effervescent drinks with meals, if tolerated.

Assess for abdominal distension, frequent belching, guarding, reluctance to move.

Ambulate and increase activity as tolerated.

Collaborative

Consult with dietitian/nutritional support team as indicated.

Begin low-fat liquid diet after NG tube is removed.

Advance diet as tolerated, usually low-fat, high-fiber. Restrict gas-producing foods (e.g., onions, cabbage, popcorn) and foods/fluids high in fats (e.g., butter, fried foods, nuts).

Administer bile salts, e.g., Bilron, Zanchol, dehydrocholic acid (Decholin), as indicated.

Monitor laboratory studies, e.g., BUN, prealbumin, albumin, total protein, transferrin levels.

Provide parenteral/enteral feedings as needed

A clean mouth enhances appetite.

May lessen nausea and relieve gas. Note: May be contraindicated if beverage causes gas formation/gastric discomfort.

Nonverbal signs of discomfort associated with impaired digestion, gas pain.

Helpful in expulsion of flatus, reduction of abdominal distension. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility 9e.g., pneumonia, thrombophlebitis).

Useful in establishing individual nutritional needs and most appropriate route.

Limiting fat content reduces stimulation of gallbladder and pain associated with incomplete fat digestion and is helpful in preventing recurrence.

Meets nutritional requirements while minimizing stimulation of the gallbladder.

Promotes digestion and absorption of fats, fat-soluble vitamins, cholesterol. Useful in chronic cholecystitis.

Provides information about nutritional deficits/effectiveness of therapy.

Alternative feeding may be required depending on degree of disability/gallbladder involvement and need for prolonged gastric rest.

LTO: After 3 days of giving effective nursing interventions, the patient was able to demonstrate progression toward desired weight gain or maintain weight as evidenced by the absence of nausea/vomiting.

Reference: Gulanick, et.al. Nursing Care Plans,

ncp

Documents

display positive response

moist mucous membranes

stable vital signs

ncp 6th edition

nursing care plans

good skin turgor

giving nursing intervention

desired weight gain