202460955-nursing-care-plan.docx
TRANSCRIPT
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Date Plan: 12-03-2013,10:00am
Name: Jungco, Esterlina Attending Physician: Dr. Dalapo
Age: 63 yrs old Admitting Diagnosis: Ovarian Adeno CA s/s TAHBSO. CHEMO
Chief Complaint: For Chemotherapy
Assessment Cues Need Nursing Diagnosis Planning Intervention Rationale Evaluation
SUBJECTIVE
Naa gihapon koy
colostomy bag as
verbalized by the
client
OBJECTIVE
Weak appearance
Presence ofcolostomy bag
(+) discomfort
Minimal
Verbalization
V/S taken as
follows
CR:75bpm
RR:20cpmTemp: 36
B/P: 100/80mmhg
SUSTENAL
CARE
NEEDS
By.
Faye Glenn
Abdellahs
Theory
Disturbed body
image related to
presence of
stoma and
colostomy bag
(Nurses Pocket
guide 12th
edition)
BackgroundStudy:
Confusion or
dissatisfaction in
mental picture of
ones physical
self-related to the
presence of
stoma and
colostomy bag.
(Nurses Pocket
guide 12
th
edition,pg.125)
After 8 hours
span of nursing
care, client will
be able to
verbalize
understanding
of body
changes.
INDEPENDENT
-Monitor Vital Signs
-Position client in her
comfort side.
-Encourage verbalization
of feelings
-Encourage client and
relatives to
communicate with each
other
-Encourage the clients
relative/family members
to treat client normallyand not as an invalid
-Encourage client to
verbalize understanding
of presence of stoma
-Provide Health
Teachings
*Instruct client of
ostomy care
-To identify physical
responses associated
with both medical and
emotional conditions.
-To promote wellness.
-To assist client and to
deal with/accept issues ofself-concept related to
body image
-To enhance handling of
potential situations.
-To help client
acceptance and not
revulsion when theclients appearance is
affected.
-to provide positive
reinforcement and
encourage client to
continue efforts and
strive for improvement
-To promote wellness
-To prevent infection
-To prevent client from
Goal partially met. Client was
able to verbalize understanding
of body changes.
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*Encourage clients
family member to help
uplift clients feeling.
*Encourage client to
engage to incorporate
therapeutic regimen into
activities of daily living
such as specific exercises
and some houseworkactivities
DEPENDENT
-Administer medication
per doctors order.
Ranitidine 50mg IVTT
every 8 hours (6-2-11)
feeling invalid.
-To accommodate
individual needs and
support indepence
- Indirectly reduces
pepsin secretion.
-Blocks daytime and
nocturnal basal gastric
acid secretion stimulated
by histamine and reducesgastric acid release in
response to foods,
caffeine, pentagastrin,
and insulin.
(Wilson,Shannon,Shields.
Pearson Nurses Drug
Guide 2012)
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Date Plan: 12-04-2013,10:00am
Name: Shimomae, Jeno Attending Physician: Dr. Natanagara
Age: 19 years old Admitting Diagnosis: Severe Viral Infection R/O Dengue Fever
Chief Complaint: Fever, General Body Malaise
Assessment Cues Need Nursing Diagnosis Planning Intervention Rationale Evaluation
SUBJECTIVE
Galuya ko as
verbalized by the
client.
OBJECTIVE
(+) discomfort
Skin warm to touch
Weak appearance
Febrile, T-37.7c
V/S taken as
follows
Temp: 37.7c
CR:80bpm
RR:21cpm
BP: 90/80mmhg
SUSTENAL
CARE
NEEDS
By.
Faye Glenn
Abdellahs
Theory
Altered
thermoregulation
related to
diseases process
as evidenced by
Temp. 37.7c
(Nurses Pocket
guide 12th
edition)
Background
Study:Temperature
fluctuation between
hypothermia and
hyperthermia can
be related to
changes in
metabolic rate or
activity.
(Nurses Pocketguide 12
thedition
pg.836)
After 8 hours
span of nursing
care, client will
be able to
increase level
of ease and
temperature
would be
lowered to
T-37c
INDEPENDENT
-Monitor Vital signs
-Encourage client to
acknowledge and to
express feelings.
-Position client on his
comfort side.
-Encourage client to
develop an exercise or
activity.
-Keep environment free
from distraction which
may be confusing or
stressful to the client.
-Provide Tepid sponge
bath
-Provide Health teaching
* Instruct clients
companion to
communicate with the
client as much as
possible.
* Encourage client toeat and provide
information regarding
-To identify physical
responses associated
with both medical and
emotional conditions.
- To assist client to
identify feelings and
begin to deal with
problems.
-To facilitate comfort.
-To create therapeutic
milieu and assist client to
develop.
-To promote wellness.
-Help reduce body
temperature level.
-to help client to develop
and entertained.
-Enhances intake andgeneral well-being.
-to maintain wellness.
Goal met. Client was able to
increase level of ease and body
temperature is decreased as
evidence by Temp-37c
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nutritionally well-
balanced diet.
*Encourage client to
drink a lot of water
DEPENDENT
-Due Medications given
as by Aps order
Ceftriaxone
(Zefaxone)
1gm IVTT every
8 hours.
-to keep client hydrated.
-Inhibits third and finalstage of bacterial cell wall
synthesis, thus killing the
bacterium.
- Effective against serious
gram-negative organisms.