Appendix b Nursing Care Plan Clinical Portait Assessment: Received Patient

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APPENDIX B NURSING CARE PLAN CLINICAL PORTAIT PERTINENT DATA Assessment: Received patient seen sitting on her bed without IVF infused, stands erect, clear vocal tone noted. The patient is conscious, attentive and oriented to time, place, and person and very cooperative. Review of Systems: Head and Neck: normocephalic, hair is evenly distributed, not extremely dry or oily, no scaled and with symmetrical facial features. No lesions noted and can breathe freely. Skin: Warm, good skin turgor, normal capillary refill noted (2 seconds) Free of edema. Mouth and Pharynx: Breath smells fresh. Lip is pinkish. Upper teeth override the lower teeth. Oral mucosa is pink, moist, smooth, and no lesions. Abdomen: The patient’s abdomen as round and large. No masses were noted and fundus was A case of Ms. R, 26 years old, female, single, Roman Catholic currently residing at Gun-ob,Lapu-Lapu ; admitted at Lapu-Lapu City District Hospital due to labor pain. Prior to admission the patient has an appointment going for a checkup while having her check-up the residence doctor advised her to go the hospital because of her complain of lower abdominal pain and blurring of vision, instead of going to the hospital patient went home and experience pain and vaginal bleeding and a blurring of vision. The family of the patient has decided to bring her to the LLCDH hospital. Upon admission through internal examination it was noted that the patient is having a baby girl twins. Already 7cm. dilated with fetal heart beat of 145 bpm. A cephalic presentation via primary low segment transverse caesarian section 2 3 36

Transcript of Appendix b Nursing Care Plan Clinical Portait Assessment: Received Patient

Page 1: Appendix b Nursing Care Plan Clinical Portait Assessment: Received Patient

APPENDIX BNURSING CARE PLAN

CLINICAL PORTAIT PERTINENT DATAAssessment:Received patient seen sitting on her bed without IVF infused, stands erect, clear vocal tone noted. The patient is conscious, attentive and oriented to time, place, and person and very cooperative.

Review of Systems:Head and Neck: normocephalic, hair is evenly distributed, not extremely dry or oily, no scaled and with symmetrical facial features. No lesions noted and can breathe freely.

Skin: Warm, good skin turgor, normal capillary refill noted (2 seconds) Free of edema.

Mouth and Pharynx: Breath smells fresh. Lip is pinkish. Upper teeth override the lower teeth. Oral mucosa is pink, moist, smooth, and no lesions.Abdomen: The patient’s abdomen as round and large. No masses were noted and fundus was at the level of the umbilicus.

Significant Findings:

The patient still feels the pain in her vaginal area. She also has small amount of vaginal discharges. She can’t sleep well at night because of the noise of babies. Restlessness noted. She was not able to defecate.

A case of Ms. R, 26 years old, female, single, Roman Catholic currently residing at Gun-ob,Lapu-Lapu ; admitted at Lapu-Lapu City District Hospital due to labor pain.

Prior to admission the patient has an appointment going for a checkup while having her check-up the residence doctor advised her to go the hospital because of her complain of lower abdominal pain and blurring of vision, instead of going to the hospital patient went home and experience pain and vaginal bleeding and a blurring of vision. The family of the patient has decided to bring her to the LLCDH hospital.

Upon admission through internal examination it was noted that the patient is having a baby girl twins. Already 7cm. dilated with fetal heart beat of 145 bpm. A cephalic presentation via primary low segment transverse caesarian section 2 degrees to placenta previa totalis posteriorly located, Vital signs of the patient showed a pulse rate of 94 beats per minute; respiratory rate of 44 cycles per minute, with a blood pressure of 150/100 mmHg and a temperature of 38.4 degree celsius through axilla. Was in labor for 4 hrs.

No history of hypertension and diabetes. No known food and drug allergies. Non-smoker and non-alcoholic beverage drinker.

LMP: January 13, 2009EDC: October 26, 2009

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AOG: 35 weeks

Vital signs taken during first contact with the patient:

Temperature: 36.5 Degrees Celsius RR: 19 breaths per minuteRR: 60 beats per minute BP: 100/80 mmHG

OB score: G1 P1

Gravida 1 female Cesarean Birth Full-term Sept. 21, 2008

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CUES/EVIDENCES NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS AND OUTCOME CRITERIA

NURSING ACTION & NURSING ORDERS

RATIONALE EVALUATION

SubjectiveCues:“Sakit ako kinataw inig pangihi nako.” , as verbalized by the patient.

ObjectiveCues:

a. Guarded behavior noted every time she moves out of bed.

b. Rates pain with intensity of 6, as 0 has no pain and 10 as the highest for pain

Alternation in comfort: pain related to perineal wound secondary to episiorrhaphy.

Sutures for an episiotomy can be sore and painful. Although relatively small in size, and episiotomy can cause considerable discomfort because the perineum is an extremely tender area. The muscled of the perineum are involved in many activities. Thus, an incision in this area causes a great

After 8 hrs. of nursing interventions, the patient will be able to verbalize alleviation of pain and discomfort.

OutcomeCriteria:Specifically, the patient will be able to:

a. Verbalize methods that provide pain relief.

b. Express of feeling of comfort.

Nursing action: Render Nursing intervention to alleviate pain and discomforts

Nursing Orders:

a. Provide Divisional activities like reading books or magazines.

b. Encourage use of relaxation technique

a. Refocuses attention may enhance coping abilities.

(Kozier, 2002: 847)

b. Imagery can be used to enhance other forms of

Goal met. After 8 hours of nursing intervention, the patient was able to verbalize alleviation of pain and discomfort from the scale of 6 reduced to 3 as 10 as the highest for pain scale.

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scale.

c. Grimaced face noted during unnecessary movements.

d. (+) episiorrhapy

deal of discomfort.

(Pillitteri, 2003: 612)

c. Verbalize reduction of pain from 4-3 scale of pain (0 as no pain & 5 as the highest).

d. Use or

such as guided imagery.

c. Asses and determine the signs of pain while taking in consideration of the location, characteristics, intensity, onset, and its duration.

d. Make time

medical & nursingtherapists to improve the body’s response to therapy. Images are meaningful to the patient need to be used. (Kozier, 2002:847).

c. Facilitate diagnosis of pain & initiation of appropriate therapy (Doenges, 1997: 38)

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SubjectiveCues:“Wala pa ko kalibang sukad gahapon unya sakit kung mosulay ko ug kalibang.” As verbalized by the Patient.

ObjectiveCues:

a. Went to the comfort room and tried to

Constipation related to loss of bowel sensation secondary to post term as evidenced by absence of stool.

Constipation tends to occur because of the relaxation of the abdominal wall and the intestine now that it is no longer compresses by the bulky uterus. For bowel movement to

demonstrate Diversio-nal activities such as reading & walking

e. Demonstrate pain relief with the use of some relaxation technique.

After 8 hrs. of nursing intervention the patient will be able to defecate.

Outcome criteria: Specifically the patient will be bale to:

a. Regain normal pattern of

to interact and maintain frequent contact with the patient.

Collaborativea. Administer

medication as ordered by the physician (mefenamic acid)

Nursing Action: Render nursing intervention to resume normal bowel movement.

Nursing Orders: Independent:

a. Review daily dietary

d. Helpful in alleviating anxiety & refocusing attention. (Kozier, 2002: 682)

e. To provide a medication that has systematic effect on the gastrointestinal tract. (Kozier, 2002: 1313)

a. Fiber absorbs water and increases stool

Goal partially met. Even though the fact that the patient was able to defecate one and half a cup but she still needs more follow up of nursing intervention to achieve resuming her normal bowel

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defecate but there room and tried to defecate but there was no stool.

b. The patient has already eaten regular meals but has not defecated yet.

occur, the abdominal wall must exert pressure. It its relaxed state, it is not strong enough to be effective. (Pillitteri, 2003: 618)

bowel functioning

b. Alters diet to include adequate amounts of fluid and fiber.

regimen. Encourage intake of roughage and increase fluid intake.

b. Encourage the patient to include fiber in the diet.

bulk which stimulates peristalsis and bowel evacuation. Likewise adequate amount of fluid will improve stool consistency ( Kozier, 2002:1193)

b. Fiber absorbs water and increases stool bulk which stimulates peristalsis and bowel evacuation. Likewise adequate amount of fluid will improve stool consistency ( Kozier, 2002:1193)

pattern.

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c. Reestablish normal bowel functioning.

d. Change diet

e. Pass stool of soft or semi formed consistency without straining.

c. Encourage early ambulation

Collaboratived. Begin progressive diet as tolerated.

e. Administer laxatives, stool softener as indicated.

c. Stimulates, peristalsis, facilitating passage of flatus. (Doengus, 2002:259)

d. Solid foods are not started until bowel sounds have returned has been passed and danger of ileus formation has abated. (Doenges, 2002:259)

e. Softens stools, promotes normal bowel habits, decreases straining. (Doenges, 2002:260)

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SubjectiveCues:“Wala pa kayo ko’u tarong nga tulog ku sige ug hilak ako anak kada gabii.” As verbalized by the patient.

ObjectiveCues:

Restlessness Noted

Dark circlesUnder the eyes

Frequent yawning.

Disturbed sleep pattern related to noise brought about by cry of the newborn.

Environment can promote or hinder sleep. The absence of usual stimuli or the presence of unfamiliar stimuli can keep people from sleep. (Kozier, 2002:956)

After 8 hours of nursing intervention, the patient will be able to verbalize that she can sleep satisfactorily.

OutcomeCriteria:Specifically the patient will be able to:

a. Evaluate sleep patter and dysfunction

Nursing Action: Render nursing intervention to have an optimal sleep pattern.

a. Obtain feedback from client regarding usual bedtime, rituals, routines, number of hours of sleep, time in arising, and environmental needs.

a. to determine the usual sleep pattern and provide comparative baseline. (Doenges, 2004:474)

Goal Met. The patient was able to verbalize satisfaction with quality and amount of sleep, and reported feelings of being rested and refreshed after waking.

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b. To assist client to establish optimal sleep/rest pattern.

c. To have regular sleeping pattern

d. Fall asleep within 30 to 45 minutes of going to bed

b. Arrange care to provide for uninterrupted periods for rest.

c. Restrict intake of caffeine- containing foods/ fluids.

d. Provides client’s desired comfort measure or sleeping aids such as appropriate positioning and supports, soft music and warm milk.

b. It enables patient to sleep uninterruptedly.(Doenges, 2002 :338)

c . Caffeine may delay patient’s falling asleep and interfere with rapid eye movement sleep, resulting in patient not feeling well rested ( Doenges, 2002; 338)

d. d. Relaxation measures help induce sleep. (Kozier, 2002:963)

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e. Reports feeling of being rested and refreshed after waking.

e. Provide a quite peaceful environment during sleeping periods.

e. A quite peaceful environment promotes restful sleep.(Kozier, 2002 :963)

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APPENDIX CDISCHARGE PLAN

PATIENT’S OUTCOME CRITERIA NURSING ORDERS

As soon as the patient is discharge from OPC the patient will be able to:

A. Assessment:

Asses the characteristic of the wound. Asses for signs of infection

B. Planning:

Plan schedules visit as ordered

Plan for correct medication to be taken

C. Implementation

Medication: Comply the medication regimen

Discuss the signs of infection such as: formation of pus swelling redness pain heat at the area

Instruct patient to follow schedule for visits

Instruct patient how to take her medication properly, what time to time and what dose.

Remind the patient and significant others of the medication schedule.

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Cefalexin (Cefalin) 500mg 1 cap TID

Celecoxib (Celebrex) 500mg 1 cap TID

Nefedipine (Adalat) 38mg 1 cap TID

Hydalazine (Apresoline) 25mg Q4

Exercise/Environment Develop routine rest and activity

Treatment Follow the schedule of medication administration

Health Teaching Do self - perineal care everyday

Out-Patient Referral Comply the schedule for check-up

Encourage client to take several naps. Instruct client to ask the physician if they will visit the clinic what is the appropriate time to resume work.

Teach patient on restriction on exercise or activity (she should not lift any object heavier than 10 lbs for the first two weeks).

Encourage the patient and significant other to help watch out for the schedule of the medication

Discuss with the patient the importance of perineal care for her fast wound recovery.

Encourage the patient and significant others to follow the given schedule.

Immediate postpartum diet is clear liquid (ginger ale, bullion, juice, water) and gradually returning to patient regular tolerated diet.

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Diet

Eat nutritious foods for faster recovery

Spiritual Attend mass every Sunday with her family.

D. Evaluation Evaluate the patient’s understanding of all the

treatment regimens and planned actions

Food should be rich in Vitamin C to prevent further infection and protein to promote wound healing.

Encourage the patient to attend mass every Sunday with her family

Let the patient repeat the instruction being said Let the patient demonstrate on the proper way to do

perineal care. Ask the patient a question to know if they really

understood the planned action

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