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B. NURSING CARE PLAN 1. NURSING CARE PLAN FOR ACUTE PAIN CUES Subjective: The verbalized, akin ngayon NURSING SCIENTIFIC OBEJECTIVE INTERVENTION RATIONALE INDEPENDENT: EVALUATION The Changes reduced often pain clients to

DIAGNOSIS EXPLANATION Acute Pain In the past, pain LONG TERM: r/t Ang ay surgical control was a major after problem After cesarean nursing client incision

pain has been the 1. Assess vital 1. signs. in these vital pain scale of 2. signs Encourage indicate of acute about and discomfort. Provide to verbalization a feelings pain the pain. pain 3. comfort measures; e.g. 3. Improves back rub, heat/ circulation, additional SHORT TERM:

masakit lang sa yung tahi ko. Objective: Patients pain scale score is 4 (Moderate Pain)

birth. Pain was intervention, so intense from the client will 2. the uterine or be abdominal have the able

incision that it reduced interfered with a in to move and womans ability scale of 2. deep breathe. (Source:

Facial grimace

Maternal Child Nursing

and After Health nursing by intervention

the cold applications.

reduces muscle tension anxiety associated with pain. and

Adelle Pillitteri)

the client will be able to 4. apply nursing intervention intended improve condtion.

Encourage Enhances

to use of relaxation sense of welltechniques; e.g. being. deep breathing 4. Relieves and muscle emotional 5. Encourage tension rest enhances sense control DEPENDENT: 6. coping Administer abilities. as analgesics of and adequate periods. exercises.

may improve

indicated as needed. 7.

to 5. To prevent

maximal dosage fatigue.

Provide with 6. maintain acceptable level of pain. To

around the clock analgesia intermittent rescue doses.

7.

Research to

supports need administer analgesics around to the clock initially prevent

rather pain.

than

merely threat

2. NURSING CARE PLAN FOR HYPERTHERMIA CUES NURSING SCIENTIFIC OBJECTIVE S INTERVENTION S INDEPENDENT: 1. Monitor the of clients After nursing the temperature. Note chills/profuse to RATIONALE EVALUATIO N The client

DIAGNOSIS EXPLANATIO Subjective: The verbalized, Mainit ang pakiramdam ko. Objective: Warm to client Hyperthermi a r/t Trauma

N In a fever, the LONG set point of the TERM: hypothalamic thermostat changes the level

was able to 1. The temperature maintain core 102F-106F temperature within normal after nursing acute range

shaking (38.9C-41.1C) suggests process. diagnosis;

suddenly from intervention to a be able

normal the client will diaphoresis.

infectious disease the pattern may aid in eg.

Fever interventions.

higher value as maintain core a result of the temperature

touch Flushed skin Measurement: T 38 C

effects tissue destruction, pyrogenic

of within normal range. SHORT

sustained continuous curves more hours than

or fever lasting 24 suggest

substances, or TERM: dehydration on the hypothalamus. (Source: Fundamentals Edition, Kozier, 488) After nursing intervention the client will be able to the to the

pneumoccocal pneumonia, scarlet of typhoid fever; fever remittent

(varying only a few degress in either direction) pulmonary infections; intermittent curves or fever that returns to normal once in 24 hour period septic suggests episode, reflects

of Nursing 7th apply page intended improve condition.

by interventions

septic endocarditis

or

tuberculosis

(TB). Chills often precede temperature 2. Monitor spikes. 2. as er of Room blankets environmental temperature, limit/add lines indicated. bed temperature/numb should be altered to maintain nearnormal temperature. 3. Provide tepid sponge avoid alcohol. DEPENDENT: 4. Administer baths, 3. May help reduce use of fever. body

antipyretics.

4. Used to reduce fever by its central axon fever who nuerotropenic asplenic. However, fever may be beneficial in limiting growth of organisms enhancing autodestruction of infected cells. or on should the be are or hypothalamus; controlled in clients

3. NURSING CARE PROCESS FOR DISTURBED BODY IMAGE

CUES

NURSING DIAGNOSI S

SCIENTIFIC EXPLANATIO N

OBJECTIV E LONG

INTERVENTIO N INDEPENDENT :

RATIONALE

EVALUATIO N The client was able to & into

Subjective:

Disturbed

If we examine TERM: lives as women, we can After see patterns emotional several nursing of intervention, the client

Body Image our As verbalized by the r/t client, feeling ko ang Pregnancy taba-taba ko.

1. A change in recognize the 1. Discuss function of be may incorporate more changes for self-concept meaning

change to client. difficult with than

some to deal without a negating selfin esteem. change appearance. 2. Have client describe self, 2. To develop &

crises. All the will be able Objective: verbalization of negative feelings ones self. about periods---the menarche, pregnancy, postpartum recovery menopause--extraordinary changes in to recognize incorporate & changes into & concept without self-esteem. appearance of &

self- noting what is new positive & what creative is negative. 3. Listen to solutions.

are marked by negating client without

body These

image. SHORT TERM: After

comments responses the the situation.

& 3.

Different to

to situations are upsetting different people,

significant body almost by corresponding emotional changes. (Source: complete postpartum guide. p.43 By: Diane Lynch-Fraser.) The

changes in the nursing are intervention, always the client 4. Visit will be able frequently to apply the acknowledge intervention improve condition.

client depending on & individual coping skills &

accompanied

the individual as past worthwhile. 4. Provides opportunities 5. Make time to for listening to sit down & concerns to questions. & talk/listen the room. 5. 6. Help client to decrease select & use sense of To

intended to someone who is experiences.

client while in

clothing make-up. 7. Refer

& isolation loneliness. to or 6. changes enhance appearance.

or

therapist counselor needed.

To &

as minimize body

7. Helpful in identifying ways/ devices to regain & maintain independence . Client may need resolve persistent further assistance to

emotional problems.

4. NURSING CARE PROCESS FOR IMPAIRED SKIN INTEGRITY CUES NURSING DIAGNOSIS Subjective: SCIENTIFIC GOAL AND INTERVENTION RATIONALE INDEPENDENT: After 1. Assess skin 1. After nursing the daily. color, circulation Note Establishes turgor, comparative and baseline providing opportunity timely nursing intervention, the client able to improved lesion wound healing. the EVALUATION

EXPLANATION OBJECTIVE The skin serves LONG line of defense

Impaired skin as the primary TERM: integrity to against bacterial

The client verbalized related Sumasakit tahi ko yong surgery kapag

invasion. When intervention, for a

gumagalaw ako. Objective:

skin is incised the client will sensation. surgical be able to be Describe and procedure, this free important line of of/display

measure lesions for

observe intervention.

Presence of surgical incision

defense is lost (Source: Maternal Child Nursing, Pillitteri p.567) Health

improvement in lesion wound

changes. 2. 2. Maintain/instruct in good hygiene; wash thoroughly, Maintaining clean, dry skin skin provides e.g., a barrier to infection. pat Patting skin

and healing. SHORT TERM:

Surgical After incisions by the removal dead damaged site cells by the with heal nursing

the dry carefully and dry instead of gently massage rubbing with lotion or reduces skin of dermal to trauma dry/fragile skin. Massaging to increases circulation to the skin and promotes comfort.

primary intervention, gradual be able

intention or by the client will appropriate to cream. and apply or Intervention cells intended new condition.

replacement of The

at the wound improve produced

surrounding tissue. (Source: Maternal Child Nursing, Pillitteri p. 582) 4. clean, wrinkle-free soft fabric. and Health 3. Reposition 3. Reduces on frequently. stress pressure points, improves blood flow to tissues promotes Maintain healing. dry, 4. Skin by and

linen, preferably friction cotton caused movement over wet/wrinkled or rough sheets leads to irritation of fragile skin

and 5. of Encourage increases risk bed as 5. Decreases pressure skin DEPENDENT: 6. alternate pressure mattress or bed. 6. skin, 7. Apply / / 7. Used in of Reduces on tissue pressure Provide bedrest. foam / flotation / prolonged on from ambulation / out of infection. tolerated.

and lesions. administer topical systemic as indicated. drugs treatment

skin lesions.

Use agents as spray stimulate circulation, enhancing 8. for exercise Refer to healing physical therapy process. regular / 8.

of such can prederm

Promotes tone skin

activity program.

improved muscle and health.

5. NURSING CARE PLAN FOR FEAR CUES NURSING DIAGNOSIS SCIENTIFIC EXPLANATION LONG INDEPENDENT: OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective: Client verbalized: Takot bumuka ko Objective: Patient move Increased respiratory has ung ako tahi gumalaw kasi baka

Fear surgical incision

r/t Fear emotion feeling

is

an TERM: or intervention, by the client will or be able to minimize her 2. pe