Nursing Care Plan

Clients Name: Patient X Age: 50 Sex: Female Final Diagnosis: Colon Cancer stage 4 post Colon Surgery. Signs and symptoms Subjective symptoms: masakit yung tahi ko. mahirap huminga kasi sumasakit yung sugat. Nursing Diagnosis Acute pain related to tissue injury secondary to surgical intervention. Analysis The client is experiencing pain due the incision made during her operation. Surgical incision resulted to trauma in the area which signals an actual tissue damage and inflammation, this damage will cause an inflammation of the nerves on the surrounding area. Inflammation of nerves can bring the presence of pain. Goals and Objectives At the end of 2 hours of nursing intervention the client should: Verbalized relief from pain. Minimize pain score upon movement to 3/10, and no pain when at rest. Change in blood pressure, heart rate to normal baseline data. Intervention Introduce self to patient. Rationale Establish nurse patient relationship. (Abdellah: to promote the development of productive interpersonal relationship.) Pain is a subjective experience and must be described by the client in order to plan effective treatment. (Abdellah: To identify and accept positive and negative expressions, feelings, and reactions) The use of noninvasive Evaluation The outcomes set are met. The client verbalizes relief of pain with absence of pain at rest and minimal pain on movement. The patient states the pain is a 2 (on a scale of 010) 30 minutes after applying of the relaxation techniques and after analgesic administration.

Mga 8 (10 is the highest pain score) yung score ng sakit pag gumagalaw at humihinga ng malalim tapos 5 pag nakahiga lang.

Perform a comprehensive assessment of pain to include location, characteristic, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain.

Objective signs: Facial grimacing. Verbal report of pain. Guarding behavior on

Teach the use of nonpharmacolog

the incision site. Elevated blood pressure (150/90) and Heart rate (98). Oxygen saturation reading 93% on room air.

ic techniques like relaxation, guided imagery, distraction, correct breathing exercises, before, after, and if possible during painful activities; before pain occurs or increases.

pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications. (Abdellah: to recognize the physiologic response of the body to disease condition) Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction. (Abdellah: To promote optimal activity, exercise,

Create a quiet, nondisruptive environment thru clustering of patients care and making the environment comfortable thru dim lights etc..

rest, and sleep.)

Check the medical order for drug, dose, and frequency of analgesic prescribed. And give the medication as ordered.

Ensures that the nurse has the right drug, right route, right dosage, right client, right frequency. (Abdellah: to use community resources as aid in resolving problems arising from illness.) Return of the vital signs to baseline is an indication of an effective pain control.

Continuously monitor the patients vital signs including blood pressure, heart rate, respiratory rate and oxygen saturation. Evaluate the effectiveness of the pain control measures used through ongoing assessment of patients pain

Most common reason for unrelieved pain is failure to routinely

experience.

assess pain and pain relief. Many patients silently tolerate pain if not specifically asked about it. (Abdellah: to facilitate the maintenance of effective verbal and non verbal communicati on; to facilitate the maintenance of regulatory mechanisms and functions.

Name: Patient X

Age: 60 y/o

Gender: Male

Clinical Diagnosis: Osteoarthritis, Right hip fracture secondary to fall post right hip pinning. Signs and symptoms Subjective symptoms: hindi ako makagalaw ng maayos. hindi ako makapunta sa banyo para umihi at dumumi. hindi ako makakapagli nis ng katawan ng ilang araw. Nursing Diagnosis Self-care deficit related to musculoskeleta l impairment post repair of fracture of the right hip as evidenced by guarding, limited range of motion (ROM) and limited use of the affected limb. Analysis After repair of right hip surgery there are limitations in the movement of the affected limb for few days which hinders the patient to be able to perform activities of daily living. The patient experience s impaired ability to perform bathing/ hygiene, dressing and grooming and toileting activities. Goals and Objectives Short term: At the end of 8 hours shift and providing of nursing intervention the client should be able to: Verbalized understanding of limitation of motion. Identify areas where he needs assistance. Long term: After 2 days of nursing interventions the patient will demonstrate techniques or lifestyle changes to meet the clients needs. Intervention Introduce self to patient. Rationale Establish nurse patient relationship. To assess the degree of disability. Evaluation The outcomes set are met. After 8 hours of nursing intervention the client verbalizes understandin g of the limitation in movement and was able to identify areas where he needs assistance. The long term goal was achieved as demonstrated by patient was able to urinate on his own thru bedside commode; was able to perform simple hygiene and grooming

Identify degree of individual impairment / functional level according to scale of impaired physical Mobility. Promote client/SO participation in problem identification and decision making. Plan time for listening to the client/SO(s)

Objective signs: Facial grimacing. Verbal report of inability to perform tasks on his own. Inability to get in and out of the bathroom due to limitation in

Enhances commitment to plan, optimizing outcomes.

To discover barriers to participation in regimen.

Provide for communicatio n among

Enhances coordination and continuity

movement. Elevated blood pressure (140/90) and Heart rate (100). Limitation in range of motion due to presence of abductor pillow between legs. Presence of contraptions such as Intravenous fluids and indwelling catheter.

those who are involved in caring for/assisting the client.

of care.

activities on his own.

Provide privacy during personal care activities. Assist with necessary adaptations to accomplish ADLs. Begin with familiar, easily accomplished tasks. Implement bladder training programs as indicated. Support client in making health-related decisions and assist in developing self-care practices and goals that promote health.

Maintains the privacy of the patient.

To encourage client and build on successes.

To facilitate removal of indwelling catheter.

To promote wellness and participation in self care.

Provide for ongoing evaluation of self-care program, identifying progress and needed changes.

To monitor the effectiveness of the activities in the health improvement of the patient and make necessary changes.

Submitted by: Camille Evan D. Ymasa

Submitted to: Prof. Celeste Dimaculangan