actual ncp final

7/29/2019 Actual NCP Final

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B. ACTUAL NURSING MANAGEMENT

1st day, assessment 2nd day, assessment

SSakit kaayo akong tibook likod ug tiyan as verbalized.

O Facial grimace

Pain Scale of 8/10, spasmic pain all over the abdominal area

Guarding on the abdominal area Self focusing; narrowed focused

AAcute Pain related to the presence of gallstones in the gallbladder

P

Long Term: At the end of 8 hours of nursing interventions, patient willbe relieved from pain felt.

Short Term: At the end of 30 minutes of nursing interventions,patient will report pain is tolerable.

I Encouraged deep breathing exercise during onset of pain Promoted bed rest and in low fowlers position

Provided comfort measures (change of position every 2 hours,therapeutic touch)

Encouraged use of diversional activities like watching tv,listening to the radio.

Administered medication as prescribed (Tramadol 50 mg slowIVTT, q8 x 3 doses then PRN) by Nurse on Duty

ELong Term: After 8 hours of nursing interventions, the patientverbalized pain was relieved

Short Term: After 30 minutes of nursing interventions, the patientreported that the pain was tolerable


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S

dili kaayu ko makatulog kung mutukar ang sakit as verbalized.

O Change in normal sleep pattern

Restless

Irritable

ADisturbed Sleep Pattern related to environmental factors( noise,ambient temperature)

PLong term: At the end of 1 day of nursing intervention n, the

patient will be able to report improve sleep and increase sense of well-being.

Short term: At the end of 4 hours of nursing intervention the patient willbe able to identify interventions to promote sleep.

I Provided a quiet environment

Provided comfort measures (touch therapy, cleaning andstraightening beddings)

Use of sleep aids (personal pillows)

Instructed to establish routine bed time and arising, think

relaxing thoughts when in bed, do not nap in the daytime Adequate rest provided

ELong term: After 1 day of nursing intervention, patient have been ableto improved sleep and increased sense of well-being.

Short term: After 4 hours of nursing intervention, the patient was ableto identify interventions to promote sleep.


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SDili kaayo ko kalihok maam kay sakitan ko as verbalized.

O

facial grimaceguarding

sleep disturbance

AActivity Intolerance related to pain on movement

PLong term: After 2 days of nursing interventions, the patientwill be able report measurable increase in activity tolerance

Short term: After 1day of nursing interventions, the patient

will to identify techniques to enhance activity tolerance

I Properly positioned the patient to avoid straining

affected areas in the body

Assisted patients needs

Assisted ADLs to help reduce discomfort and avoidtoo much energy exertion

Encouraged frequent position changes (side-lying tosupine) when on bed rest

Encouraged bed rest

ELong term: After 2days of nursing interventions, the patient

was able to report measurable increase in activity tolerancemanifested by walking without assistance.

Short term: After 1 day of nursing interventions, the patientwas able to identify techniques to enhance activity tolerance


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S

Gakakulbaan ko sa akong operasyon karon kay last nakonga opera, gi-intubate man gud ko as verbalized

O Verbalize awareness of feelings

Anxious

Restlessness

Preoccupied from her last operation experience

AAnxiety related to upcoming operation

PLong term: After 1 hour of nursing interventions, thepatient will appear relaxed and report anxiety reduced toa manageable level.

Short term: After 30 minutes of nursing interventions, thepatient will verbalize awareness of feelings of anxiety

IEstablished a therapeutic relationship, conveying

empathy and unconditional positive regard.

Be available to client for listening and talking

Encouraged client to acknowledge and to expressfeelings

Providedinformation regarding disease process and

anticipated treatmentProvided comfort measures(e.g., calm/quiet

environment, therapeutic touch)

Provided adequate rest

Instructed in ways to use positive talk, e.g., I canhandle this

ELong term: After 1 hour of nursing interventions, thepatient appeared relaxed and reported reduced anxietymanifested by socialization engagement(talking with otherpatients and laughing with them).

Short term: After 30 minutes of nursing interventions, thepatient was able to verbalize understanding of her presenthealth status that lessened her anxiety.


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Sgasakit akong tahi kung mulihok ko as verbalized by patient

O (+) Facial grimace

Pain scale of 5 out of 10,

Self-focusing; narrowed focus

AAcute pain related to post-op surgical incision

PLong term: After 8 hours of nursing interventions, the patient willdemonstrate techniques to alleviate/control pain.

Short term: After 30 minutes of nursing interventions, the patient willreport relief of pain

I Encouraged deep breathings during onset of pain

Positioned client to where she is comfortable

Taught client diversional activities like watching television

Have the patient splint incision when moving

Provided adequate rest periods Provided a calm, quiet environment

Administered analgesic (ketorolac 300 mg IVTT,q6 x 4 doses) byNurse on Duty

ELong term: The patient was able to demonstrate techniques to alleviatepain

Short term: The patient reported that the pain was lessened


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Sgasakit akong tahi kung mulihok ko as verbalized by patient

O Sugical dressing on RUQ Disruption of the skin surface

Injury on the skin layers

AImpaired skin integrity related to surgical incision

P

Long term: After 2 days of nursing interventions, the patient will achievetimely wound healing without complications

Short term: After 1 day of nursing interventions, the patient willdemonstrate behaviors to promote healing/prevent skin breakdown

I Changed dressings and do wound care as often as necessary Placed patient in low- or semi-Fowlers position Maintained T-tube in closed collection system

Administered antibiotics(cefuroxime 350 mg, IVTT q8) by Nurseon Duty

ELong term: After 2 days of nursing intervention, the patient was able to

maintained the wound intact and free from complications

Short term: After 1 day of nursing intervention, the patient verbalizedunderstanding of proper wound care and demonstrated the proper wayto do it.


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S

O

Slightly febrile (37.7 degrees celcius)

WBC : 13.7 (4.50-11.0) x 10^ g/uL

Presence of post-operative wound at right upper quadrant of theabdomen

With penrose drainage

ARisk for infection related to presence of post-operative wound

P

Long term: After 8 hours of nursing interventions, the patient willdemonstrate techniques in reducing risk of having infection.

Short term: After 4 hours of nursing interventions, the patient willachieve timely wound healing, be free of purulent drainage, be afebrile.

I Stressed proper hygiene

Emphasized importance of daily change dressings

Increased oral intake

Maintained adequate nutrition (

Maintained adequate rest

ELong term: After 8 hours of nursing interventions, the patient was ableto demonstrate techniques in reducing risk of having infection

Short term: After 4 hours of nursing interventions, the patient wasafebrile and free from purulent drainage.


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actual ncp final

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