ASSESSMENT

OBJECTIVE DATA >BP: 140/80 >RR:22 >Poor eye contact >Patient is anxious

NURSING DIAGNOSIS (RATIONALE) Anxiety related to situational crisis (Patient has uneasy feeling regarding the possible result of his impending surgery)

PLAN >OBJECTIVES Within the 8 hours of nursing intervention and implementation, the patient will be relieved from the anxiety that he feels. >to be more expressive of what he feels >to appear more relax and report anxiety is more manageable >to exhibit increased in interest to communicate with others >to identify healthy ways to deal with and expressed anxiety >to demonstrate problem-solving skills

INTERVENTION

RATIONALE

IMPLEMENTATION

EVALUATION

1. Assess level of anxiety by the following: >monitoring vital sign >observing behavior 2. Assist the patient to identify feelings and begin to deal with problems by: >establishing a therapeutic relationship, conveying empathy, and unconditional positive regard >be available to patient for listening and talking >provide accurate information about the situation 3.Assess the patients motivation 4. To develop learners objective 5. Administer medication as prescribe by the physician

1. These can point the patients level of anxiety as to mild, moderate, severe or panic and identify physical responses associated with both medical and emotional conditions 2.These is to: >avoid the contagious effect or transmission of anxiety >encourage the patient to acknowledge and to express feelings >helps patient to identify what is reality based

1. Monitor vital signs every 4 hrs.

SUBJECTIVE DATA >Patient expressed concerns regarding change in daily activity. >Patient expressed desire to go home >Patient apathy to communicate with others

Within the 8 hours of nursing intervention and 2. Provided implementation, preoperative care for the patient was the client relieved from the anxiety that feels 3. Taught the and is able to sleep significant others to do soundly. therapeutic touch in case the patient is in pain. 4.Provided health education to client by doing a bedside clinic

5. Done NPI to 3. Motivation can be encouraged patient negative stimulus or positive expressed how is he doing and to alleviate 4. To know urgent need the anxiety he feels from both patients and (therapeutic nurses viewpoint communicaton). 5. These medications can heighten feelings and sense of anxiety

ASSESSMENT

OBJECTIVE DATA >Liquid diet for two days >Pale skin and lips >No IV therapy >Almost two months hospitalization >wt: 55kg >age:53 SUBJECTIVE DATA >Patient verbalized that when IV insertion site was painful already it is removed; however, sometimes it is not put back immediately because some nurse on duty is having a hard time to find the right vein for it. >Tig laag sa tupperware, dai man kaya ako pwede kayan saka dai ko gusto pagkakan digdi sa ospital, as patient verbalized. >Patient verbalized that he feels weak >Dati ngani mataba man

NURSING DIAGNOSIS (RATIONALE) Imbalance nutrition: less than body requirement related to psychological factors

PLAN >OBJECTIVES Within the 8 hours of nursing intervention and implementation, the patient will be able to understand the importance having balance nutrition and weight gain to hospital recovery >to demonstrate behavior and lifestyle changes to regain or maintain appropriate weight. >to verbalize understanding of causative factors when known and necessary interventions >to demonstrate progressive weight gain toward goal

INTERVENTION

RATIONALE

IMPLEMENTATION EVALUATION

1. Assess causative/contributing factors: >identify client risk for malnutrition >determine clients ability to chew, swallow and taste food >discuss eating habits, including food preferences, intolerances or aversions. 2. Evaluate degree of deficit: >assess weight, measure or calculate body fat and BMI >Assist in nutritional assessment, using screening tools 3. Establish a nutritional plan that meets individual needs >Note age, body build, strength, activity and rest level >Evaluate total daily

1.>To provide baseline date >To identify factors that can affect ingestion and/or digestion of nutrients >To appeal to clients tastes 2.To establish baseline parameters 3.>Help determine nutritional needs >To reveal possible cause of malnutrition and changes that could be made in clients intake >To implement interdisciplinary team management 4. For a lifelong effectiveness of dietary plan

1. Monitor I&O, vital sign 2. Change and regulate IV to appropriate drops per min. 3. Provide health teaching regarding bowel preparation ( before and after surgery) 4. Encourage patient to follow prescribe diet 5. Encourage SO to strictly monitor patient diet

Within the 8 hours of nursing intervention and implementation, the patient has able to understand the importance having balance nutrition and weight gain to hospital recovery

yan si papa kaso haluyon naospital, as the SO verbalized

food intake >Consult dietitian or nutritional team, as indicated. 4. Promote wellness >Emphasize importance of wellbalanced, nutritious intake. Provide information regarding individual nutritional needs and ways to meet these