c
   c
c


c
 



  
 

 
 
c 

„
 Alteration in The most After 8 hours of
 
 Comfort: characteristic holistic nursing 1.Provide comfort 1.Promote non-
Lumbar Pain manifestation care, the patient measures like touch pharmacological
Occurrence related to of renal calculi will be able to: therapy, back rubs pain management
of pain was 6 presence of is a sharp, Ê
 
 
hours before calculi in the severe pain of 1.Verbalize a !  "
# 
admission; left kidney sudden onset decreased   # 
pain is at the secondary to caused by sensation of $  #%
lumbar Nephrolithiasis movement of pain by a
region with a the calculus change in the
duration of 5 and consequent patient¶s scale
minutes irritation. Renal from 9 to a 2.Promote diversional 2. To distract
every onset colic originates score of 5 activities such as attention from pain
for more deep in the watching television and reduce tension
than 10 lumbar region 2. Manifest Ê
 
 
times and radiates absence of pain !  "
# 
a day around the side as evidenced by   # 
intermittent and down absence of $  #%
pain toward the facial grimace
characterized testicles in the
by sharp, male. Pain
severe pain may be
aggravated intermittent, 3.Teach deep 3.Helps combat
during which usually breathing exercises fatigue and muscle
micturition; means that tension that occurs
Pain scale of stone has with increased pain
9; BP at moved. Ê
 
 
170/20; Pressure !  "
# 
Temperature: against bladder   # 
37.5 degree during $  #%
Celsius; micturition can
Pulse rate: cause a heavy
75 bpm feeling in the
Ultrasound subrapubic 4.Eliminate additional 4. Patient may
revealed area. stressors or talk to experience an
patient about positive exaggeration in
Ê
 Ê
 things pain or decreased
 
  
 ability to tolerate
Ê
 
 painful stimuli if
³ Sakit man 
    there are factors
ako pantog     that are further
ug ako pud   
 stressing them.
likod, labi na  Ê
 
 
og mangihi !  "
# 
ko´ as   # 
verbalized $  #&
by the
patient.
 5.Encourage patient to 5.To promote
have adequate rest wellness and
periods decrease attention
of pain
Ê
 
 
!  "
# 
  # 
$  #%'

6.Monitor vital signs 6. Vital signs are

every 4 hours as usually altered in
ordered by the pain and and to
physician identify appropriate
interventions if
vital signs
increased/decreased
Ê
 
 
!  "
# 
  # 
$  #%

7. To maintain
acceptable level of
pain
7. Administer Ê
 
 
antispasmodic as !  "
# 
ordered like Buscopan   # 
as ordered by the $  #%'
physician

c
   c
c


c
 

  
 

 
 
c 
 

„
 Impaired Skin When the After 8 hours of 1. change 1.these measures
 
 Integrity: appendix holistic nursing dressings prevent skin
Presence of becomes care, the patient frequently as irritation
Presence incision related obstructed, the will be able to needed Ê

of suture to tissue trauma intraluminal improve skin ) 
  
wounds in secondary to pressure integrity as ( 

 

the Right a appendectomy increases, evidenced by 
  
lower leading to absence of pus 


* (
abdomen; decreased and infection. +  +%¦
venous
BP: drainage, 2. Observe the 2. To monitor
180/50 thrombosis, surgical progress of
PR: edema and incision for wound healing.
80bpm bacterial complications Ê
 
 
Temp: 37 invasion the !  "
#
degree lumina.    # 
Celsius Arterial $  #,'
compromise
occurs with 3. Keep the 3. To assist
necrosis and area clean and body¶s natural
invasion of the dry repair
bowel wall. If Ê
 
 
the process !  "
#
Ê
 develops    # 
 
 slowly, the $  #,'
³ Sakit pa infection may
ilihok ang be walled off 4. Use 4. To protect the
akoang by the adjacent appropriate wound
lawas kay structures, barrier surrounding
tungod sa forming an dressings or tissues.
tahi na naa abscess. wound Ê

 
sa akong m ( coverings ! "
#
tiyan´ as involves   #
verbalized removal of the $  #,'
by the appendix 
patient. within 24 to 48 5. In changing 5.To prevent
hours of onset the dressings, infection
of the incision .
manifestations. should be Ê

 
The surgery checked ! "
#
can be simultaneously   #
performed for redness, $  #%'
through a small swelling,
open incision. drainage
 characteristics,
Ê
 amount and
 
 odor.
Ê
 


   
6. To splint or
    6. Ensure that
  
 dressing are immobilize the
,& secure but not
wound
constrictive
Ê

 
! "
#
  #
$  #,''

7. Vital signs are

usually altered in
7. Monitor pain and and to
Vital Signs identify
every 15 appropriate
minutes for 2 interventions if
hours vital signs
increased/decreas
ed
Ê
 
 
!  "
#
   # 
$  #%






















 c
   c


c
 

 
 
 
 c 
c 
 


„
 Anticipatory In some After 1. Provide a 1. This
 
 Grief related to respects, the safe assumes a
perceived loss of pain that environment tolerance for
-weight loss lower extremities accompanies for expression the patient¶s
grieving results of grief. expression of
-social from a Minimize grief.
withdrawal disturbance in environmenta Ê

the person¶s l stresses or 
   /

-lack of belief. The loss stimuli. !
 , 
energy disrupts, if not    
shatters, basic -
- appetite assumptions 2. Remain 2. The patient
disturbances about life¶s with patient may need a
meaning and throughout trusted person
-sleep purpose. difficult times present to
disturbances Grieving often represent their
causes a person interest or
-altered to change feelings if they
activities of beliefs about feel unable to
daily living self and the express them.
world. Ê

Ê
 Changes in 
   /

 
 thinking and !
 , 
 attitude include    
³ Sakit kayo reviewing and &
ning ranking values 3. Identify 3.
mawad-an ta and shedding behaviors Manifestations
og tiil, dili illusions about suggestive of of grief are
nako viewing the the grieving strongly
katrabaho. world more process influenced by
Ma unsa realistically, factors. The
naman lang and re- health care
mi ani?´ as evaluating provider can
verbalized religious or enter
by the spiritual dangerous
patient. beliefs. territory when
 he or she
Ê
 attempts to
!
  categorize grief
 
   - as
    inappropriate.
.  Ê

''& 
   /

!
 , 
   
-
4. Help the 4. This allows
patient the nurse and
prioritize the patient to focus
importance of rehabilitative
rehabilitation energy on
needs. those things
that are
greatest
importance to
the patient.
Ê


   /

!
 , 
   
-

5. Encourage 5. Patient may

verbalization feel supported
of thoughts in expression
and concerns. of feelings.
Ê


   /

!
 , 
   
$  
&

6. Show 6. This is the

support and same strength
positively and reserve
reinforce the each of them
patient¶s will use to
efforts to go reconstitute
on with his their lives after
life and ADL. the loss.
Ê


   /

!
 , 
   
-
7. Be aware 7. May be
of mood patient¶s way
swings, of
evidenced of expressing/deal
conflict, ing with
expressions of feelings of
anger and despair
other acting- reflecting
out behavior. ineffective
coping.
Ê


   /

!
 , 
   
-