SWCP - NCP
SWCP - NCP
SWCP - NCP
Assessment Subjective data: kanang mura ug gikalitan ug tusok nga kanang sakit jud basta kay sakit jud eh lihok-lihok mao na nga gapuyo nalang jud ko sa akong katre para mawala-wala pud ang kasakit as verbalized by the client. Diagnosis Pain related to multiple stab wounds Planning Short term: after 5 minutes of nursing intervention the client will be able to: y report pain is relieved or controlled y verbalize nonpharmacologic methods that provide relief y demonstrate use of relaxation skills and diversional activities as indicated for situation Long term: After 1 hour of nursing interventions the client will be able to: - nonrecurrence of pain y demonstrate use of relaxation skills and diversional activities as Interventions Independent: Encourage verbalization of feelings about pain Provide comfort measures, such as: touch, repositioning, use of heat or cold packs, quiet environment and calm activities Instruct in and encourage use of relaxation techniques, such as focused breathing, imaging Encourage diversional activities Review procedures and expectations including when treatment may cause pain Encourage adequate rest periods to reduce concern of the unknown and associated muscle tension to prevent fatigue Rationale Evaluation Short Term: The Client was able to verbalize relief from pain and used nonpharmacologic methods to relieve it. And was able to correctly demonstrate relaxation skills and diversional activities.
To lessen anxiety
Objective data: y Pain scale of 7 out of 10 y guarding behaviour y protective gestures y facial grimacing y diaphoresis y change in vital signs: HR= 94bpm, RR= 25cpm
Long Term: Pain was further controlled by its nonrecurrence and client was able to effectively use diversional and relaxation skills in every event of pain.
Collaborative: Administer analgesics, as indicated, to maximum dosage - to maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal.
To provide a pharmacologic pain management when pain cannot be reduced by other measures used.
Interventions Independent: y Promote surface cooling by means of undressing y provide cool Environment and/or fans y cool, tepid sponge baths or immersion y provide local ice packs, especially in groin and axillae Maintain Bedrest Discuss importance of adequate fluid intake
Rationale
heat loss by radiation and conduction heat loss by convention heat loss by evaporation and conduction these are areas of high blood flow to reduce metabolic demands and oxygen consumption to prevent dehydration
y y
Collaborative: Monitor use of hypothermia blanket and wrap extremities with bath towels Provide high-calorie diet
to minimize shivering
Long Term: The client was able to correctly demonstrate behaviors on how to control hyperthermia and was free from any complications.
Short term: Independent: After of nursing - Describe and intervention the client will measure wounds be able to display and observe imporovement in wound changes healing as evidenced by: - Promote optimum nutrition with highy intact skin or quality protein and minimized sufficient calories, presence of wound vitamins, and y absence of mineral redness or supplements erythema - Encourage y verbalize adequate understanding of adequate periods condition and of rest and sleep causative factors y identify interventions - Limit or avoid use appropriate for of caffeine , specific condition alcohol, and y Demonstrate medication behaviours and affecting REM lifestyle changes to sleep promote healing and prevent - Provide teaching complications or on oral hygiene, recurrence avoiding extremes of hot or cold,
to facilitate healing
to limit metabolic demands,maximizi ng energy available for healing, and meet comfort needs May be necessary to determne extent of impairment to prevent damage to mucous membranes
Long Tem: After of nursing interventions the client will be able to: y Wound is less than ---y Display progressive improvement in wound or lesion healing y Be infection free until client is discharged
Collaborative: - Assist with diagnostic procedures - Provide appropriate protective and healing devices (e.g., padding or cushions.therapeuti c bed and mattresses, chronic ulcer dressing , compression wrap.
May be necessary to determne extent of impairment To prevent further damage or complication to existing problem.
Short term: Independent: After of nursing - Describe and intervention the client measure wounds will be able to display and observe imporovement in wound changes healing as evidenced by: - Promote optimum nutrition with highy intact skin or quality protein and minimized sufficient calories, presence of wound vitamins, and y absence of mineral redness or supplements erythema - Encourage y verbalize adequate understanding of adequate periods condition and of rest and sleep causative factors y identify interventions - Limit or avoid use appropriate for of caffeine , specific condition alcohol, and y Demonstrate medication behaviours and affecting REM lifestyle changes sleep to promote healing and prevent - Provide teaching complications or on oral hygiene, recurrence avoiding extremes
to facilitate healing
to limit metabolic demands,maximizi ng energy available for healing, and meet comfort needs May be necessary to determne extent of impairment to prevent damage to mucous membranes
nga ako lang mag lihok-lihok kinahanglan pa jud nako ug tabang kung naa man koy buhaton kay dili jud nako makaya nga ako ra
Long Term: Maintained position function, skin integrity as evidenced by ---and there was an increase in strength and function of affected body part.
Collaborative: y Assist with treatment of underlying condition causing pain and/or dysfunction Administer medications prior to activity as needed for pain relief Consult with physical or occupational therapist to permit maximal effort and involvement in activity to develop individual exercise and mobility program, and identify appropriate mobility devices
Long Term: After of nursing interventions the client will be able to: achieve timely wound healing; Client will be infection free until patient is discharged.
to prevent contamination
Long Term: The client was able to achieve timely wound healing and was discharged free from infection(s).
Reduces risk of ascending UTI Premature discontinuation of therapy when client begins to fell well may result in return if infection and potentiation of drug-resistant strains
Collaborative: - Assist with medical procedures - administer and monitor medication regimen - Administer prophylactic antibiotics - Identify resources available to the individual