Вы находитесь на странице: 1из 5

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues) NURSING DIAGNOSIS (Problem and Etiology) GOALS

AND OBJECTIVES Short term: After 1 hour of nursing intervention, the patient will verbalize understanding through the use of effective coping behaviors . A Long term: After 2 days of nursing intervention, the patient will display appropriate range of feelings and lessened fear and gain information about the procedure. NURSING INTERVENTIONS AND RATIONALE
Establish patients rapport to gain trust and cooperation. Monitor and record patients vital signs to obtain baseline data. Determine what the patient is fearful of, and thoughtful questioning because patient who find it unacceptable to express fear may find it helpful to know that someone is willing to listen if they do decide to share their feelings at sometimes in the future. Compare verbal and non verbal responses to note congruence or misperceptions in the situation. Assess the degree of fear and the measures patient uses to cope with that fear. This helps determine the effectiveness of coping strategies used by the patient. Maintain a calm and tolerant manner while interacting with patient. The patients feeling of stability increases in a calm and nonthreatening atmosphere and ongoing relationship establishes trust and a basis for communicating fearful feelings. Establish a working relationship through continuity of care. If home environment is unsafe, patients fears are not resolved and fear may become disabling. Encourage rest periods, rest improves ability to cope. Exercise in relaxation, meditation, or guided imagery. Exercise reduces the physiological response to fear.

EVALUATION

Subjective: Anxiety related to deficient nabalaka ko kung unsa knowledge of the procedure. mahitabo sa ako as verbalized. Objective: Fright Fatigue Narrowed focus

Goals met. Short term: Patient was able to demonstrate understanding through the use of effective coping behaviors and resources. Long term: Patient was able to display appropriate range of feelings and lessened fear and gain information about the procedure.

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues) Subjective: gitang-tang akong wala nga soso as verbalized. Objective:

NURSING DIAGNOSIS (Problem and Etiology) Impaired tissue integrity related to removal of breast.

GOALS AND OBJECTIVES Short term: After 1 hour of nursing intervention, the patient will participate in prevention measures and treatment program. Long term: After 1-2 days of nursing intervention, the patient will be able to display progressive improvement in wound healing.

NURSING INTERVENTIONS AND RATIONALE


Establish patients rapport to gain trust and cooperation. Monitor and record patients vital signs to obtain baseline data. Assess incision site, take note of size, color, location, temperature, texture, consistency of wound lesion to provide comparative baseline data. Inspect surrounding skin for erythema, induration, maceration to assess extent of involvement. Assess for odors and drains coming out from the skin area of injury to assess early progression of of wound healing, developmental of hemorrhage or infection. Keep the area clean/dry, carefully dress wounds, support incisions and prevent infection to assist bodys natural process of repair. Encourage an increase in protein intake to aid in timely wound healing for the patient. Encourage early ambulation and mobilization to promote circulation and reduce risks associated with immobility. Practice asceptic technique in cleaning/dressing and medicating lesions to reduce risk of cross contamination. Instruct proper disposal of soiled dressing. To prevent spread of infectious agent.

EVALUATION Goals met. Short term: Patient was able to participate in prevention measures and treatment program. Long term: Patient was able to display progressive improvement in wound healing.

Presence of surgical wound in the breast where incision was made. Numbness in the surrounding area redness

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues) Subjective Cues: sakit akong inoperahan as verbalized. Objective Cues: Pain scale of 8/10 facial grimace restlessness guarded behaviour sleep disturbances NURSING DIAGNOSIS (Problem and Etiology) Acute pain related to postoperative incision GOALS AND OBJECTIVES Short term: After 1 hour of nursing intervention patients pain scale will be reduce. Long term: After 2 days of nursing intervention patient will be relieve from pain and will appear more relax. NURSING INTERVENTIONS AND RATIONALE Monitor vital signs to for baseline data. Assess verbal/non-verbal reports of pain, noting location, intensity (0-10 scale), and duration for useful evaluating pain, choice of interventions, effectiveness of therapy. Instruct client to use hands to support neck during movement and to avoid hyperextension of neck for movement restriction is imposed for only a few hours postoperatively to prevent stress on the suture line and reduce muscle tension. Gentle flexing and stretching is then permitted according to pain tolerance to help prevent neck soreness. Encourage patient to use relaxation techniques e.g.,guided imagery, soft music, progressive relaxation to help refocus attention and assist patient to manage more effectively. Instructed to eat soft foods. It may tolerated better than liquids if patient is experienced difficulty of swallowing. EVALUATION Goals partially met. Short term: Patients pain scale was 5/10 from 8/10. Long term: Patient was able to rest at intervals but pain is still felt.

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues) Subjective: dili nako mabuhat ang gusto nako buhaton tungod sa akong operasyon as verbalized. Objective: Limited range of motion Immobility Inability to turn sides Inability to change position Inability to transfer from bed to chair NURSING DIAGNOSIS (Problem and Etiology) Activity intolerance related to post operative wound GOALS AND OBJECTIVES Short term: After 1 hour of nursing intervention the patient and the significant others will be able to identify negative factors affecting activity tolerance and eliminate/reduce their effects. Long term: After 2 days of nursing intervention, the patient will be able to improve her activity and perform techniques to enhance activity tolerance. NURSING INTERVENTIONS AND RATIONALE Establish patients rapport to gain trust and cooperation. Monitor and record patients vital signs to obtain baseline data. Assess patients condition, to obtain baseline data to be used in evaluating patients condition. Assess patients level of mobility. This aids in defining what patient is capable of, which is necessary before setting realistic goals. Assess nutritional status. Adequate energy reserves are required for activity. Provide a quite environment and encourage use of stress management. Rest provides time for energy conservation and recovery. Assist client in learning and demonstrating appropriate safety measures. To enhance sense of well being. Encourage client to maintain positive attitudes; suggest use of relaxation techniques such as visualization/guided imagery as appropriate. EVALUATION

Goals met. Sort term: Patient was able to identify negative factors affecting activity tolerance and eliminate/reduce their effects. Long term: Patient was able to improve her activity and perform techniques to enhance activity tolerance.

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues) SUBJECTIVE Luya akong lawas as verbalized. OBJECTIVE: Hemoglobin 8.9 g/dl Hemovac drainage 400cc Vital signs: NURSING DIAGNOSIS (Problem and Etiology) Fatigue related to decreased hemoglobin concentration in blood secondary acute blood loss. GOALS AND OBJECTIVES After 2 hours of nursing interventions, the client will manifest the following: Short-term goal: Demonstrate increased perfusion as individually appropriate BP=120/80mmHg RR=18 cpm Capillary refill less than 3 sec Long-term goals: After 4 hours of nursing interventions, the client will manifest the following: Demonstrate behaviors/lifestyle changes to improve circulation. NURSING INTERVENTIONS AND RATIONALE INDEPENDENT 1. Measure capillary refill; palpate for presence/absence and quality of pulses. R: To assess blood flow distributed to extremities. 2. Encourage active or assist with passive leg exercises, with avoidance of isometric exercises. Enhances venous return, reduces venous stasis, and decreases risk of thrombophlebitis. 3. Provide supplemental oxygen as prescribed R: To increase oxygen supply to the myocardium. 4. Monitor vital signs and measure urine output on a regular schedule. R: (Intake may be calculated against output.) 5. Monitor intake and output R: To prevent circulatory overload. DEPENDENT 7. Administer medications with caution as indicated. R: Drug response, half-life, toxic levels may be altered by decreased tissue perfusion. EVALUATION After 2 hours of nursing interventions, the client has manifested the following: Goal met: Demonstrate increased perfusion as individually appropriate BP=120/80mmHg RR=18 cpm Goals partially met: Demonstrate behaviors/ lifestyle changes to improve circulation Capillary refill less than 3 sec