appendix b nursing care plan clinical portait assessment: received patient
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APPENDIX B NURSING CARE PLAN CLINICAL PORTAIT Assessment: Received patient seen sitting on her bed without IVF infused, stands erect, clear vocal tone noted. The patient is conscious, attentive and oriented to time, place, and person and very cooperative. Review of Systems: Head and Neck: normocephalic, hair is evenly distributed, not extremely dry or oily, no scaled and with symmetrical facial features. No lesions noted and can breathe freely. Skin: Warm, good skin turgor, normal capillary refill noted (2 seconds) Free of edema. Mouth and Pharynx: Breath smells fresh. Lip is pinkish. Upper teeth override the lower teeth. Oral mucosa is pink, moist, smooth, and no lesions. Abdomen: The patients abdomen as round and large. No masses were noted and fundus was at the level of the umbilicus. Significant Findings: The patient still feels the pain in her vaginal area. She also has small amount of vaginal discharges. She cant sleep well at night because of the noise of babies. Restlessness noted. She was not able to defecate. PERTINENT DATA A case of Ms. R, 26 years old, female, single, Roman Catholic currently residing at Gun-ob,Lapu-Lapu ; admitted at Lapu-Lapu City District Hospital due to labor pain. Prior to admission the patient has an appointment going for a checkup while having her check-up the residence doctor advised her to go the hospital because of her complain of lower abdominal pain and blurring of vision, instead of going to the hospital patient went home and experience pain and vaginal bleeding and a blurring of vision. The family of the patient has decided to bring her to the LLCDH hospital. Upon admission through internal examination it was noted that the patient is having a baby girl twins. Already 7cm. dilated with fetal heart beat of 145 bpm. A cephalic presentation via primary low segment transverse caesarian section 2 degrees to placenta previa totalis posteriorly located, Vital signs of the patient showed a pulse rate of 94 beats per minute; respiratory rate of 44 cycles per minute, with a blood pressure of 150/100 mmHg and a temperature of 38.4 degree celsius through axilla. Was in labor for 4 hrs. No history of hypertension and diabetes. No known food and drug allergies. Non-smoker and non-alcoholic beverage drinker. LMP: January 13, 2009 EDC: October 26, 2009
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AOG: 35 weeks Vital signs taken during first contact with the patient: Temperature: 36.5 Degrees Celsius RR: 19 breaths per minute RR: 60 beats per minute BP: 100/80 mmHG OB score: G1 P1 Gravida 1 female Cesarean Birth Full-term Sept. 21, 2008
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NURSING SCIENTIFIC DIAGNOSIS BASIS Alternation in comfort: pain related to perineal wound secondary to episiorrhaphy. Sutures for an episiotomy can be sore and painful. Although relatively small in size, and episiotomy can cause considerable discomfort because the perineum is an extremely tender area. The muscled of the perineum are involved in many activities. Thus, an incision in this area causes a great deal of
GOALS AND OUTCOME CRITERIA After 8 hrs. of nursing interventions, the patient will be able to verbalize alleviation of pain and discomfort. Outcome Criteria: Specifically, the patient will be able to: a. Verbalize methods that provide pain relief.
Subjective Cues: Sakit ako kinataw inig pangihi nako. , as verbalized by the patient. Objective Cues: a. Guarded behavior noted every time she moves out of bed. b. Rates pain with intensity of 6, as 0 has no pain and 10 as the highest for pain scale.
NURSING ACTION & NURSING ORDERS Nursing action: Render Nursing intervention to alleviate pain and discomforts Nursing Orders:
Goal met. After 8 hours of nursing intervention, the patient was able to verbalize alleviation of pain and discomfort from the scale of 6 reduced to 3 as 10 as the highest for pain scale. a. Refocuses attention may enhance coping abilities. (Kozier, 2002: 847) b. Imagery can be used to enhance other forms of medical &
a. Provide Divisional activities like reading books or magazines. b. Encourage use of relaxation technique such as
b. Express of feeling of comfort.
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discomfort. c. Grimaced face noted during unnecessa ry movement s. (+) episiorrha py c. Verbalize reduction of pain from 43 scale of pain (0 as no pain & 5 as the highest). (Pillitteri, 2003: 612)
nursing therapists to improve the bodys response to therapy. Images are meaningful to the patient need to be used. (Kozier, 2002:847). c. Facilitate diagnosis of pain & initiation of appropriate therapy (Doenges, 1997: 38)
c. Asses and determine the signs of pain while taking in considerati on of the location, characteris tics, intensity, onset, and its duration. d. Make time to interact and
d. Use or demonstrate Diversio-nal
d. Helpful in
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activities such as reading & walking
maintain frequent contact with the patient. Collaborative a. Administer medication as ordered by the physician (mefenami c acid) Nursing Action: Render nursing intervention to resume normal bowel movement. Nursing Orders: Independent:
alleviating anxiety & refocusing attention. (Kozier, 2002: 682) e. To provide a medication that has systematic effect on the gastrointestinal tract. (Kozier, 2002: 1313) Goal partially met. Even though the fact that the patient was able to defecate one and half a cup but she still needs more follow up of nursing intervention to a. Fiber absorbs achieve water and resuming her increases stool normal bowel bulk which pattern. stimulates peristalsis and
e. Demonstrate pain relief with the use of some relaxation technique. Subjective Cues: Wala pa ko kalibang sukad gahapon unya sakit kung mosulay ko ug kalibang. As verbalized by the Patient. Objective Cues: a. Went to the comfort room and tried to defecate but there room and tried to Constipation related to loss of bowel sensation secondary to post term as evidenced by absence of stool. Constipation tends to occur because of the relaxation of the abdominal wall and the intestine now that it is no longer compresses by the bulky uterus. For bowel movement to occur, the abdominal wall must After 8 hrs. of nursing intervention the patient will be able to defecate. Outcome criteria: Specifically the patient will be bale to: a. Regain normal pattern of bowel functioning
a. Review daily dietary regimen. Encourage intake of
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defecate but there was no stool. b. The patient has already eaten regular meals but has not defecated yet.
exert pressure. It its relaxed state, it is not strong enough to be effective. (Pillitteri, 2003: 618)
roughage and increase fluid intake.
bowel evacuation. Likewise adequate amount of fluid will improve stool consistency ( Kozier, 2002:1193) b. Fiber absorbs water and increases stool bulk which stimulates peristalsis and bowel evacuation. Likewise adequate amount of fluid will improve stool consistency ( Kozier, 2002:1193)
b. Alters diet to include adequate amounts of fluid and fiber.
b. Encourage the patient to include fiber in the diet.
a. Reestablish normal bowel functioning.
c. Encourage c. Stimulates, early peristalsis, ambulation facilitating passage of
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flatus. (Doengus, 2002:259) b. Change diet Collaborative d. Begin progressive diet as tolerated. d. Solid foods are not started until bowel sounds have returned has been passed and danger of ileus formation has abated. (Doenges, 2002:259) e. Softens stools, promotes normal bowel habits, decreases straining. (Doenges, 2002:260) Goal Met. The patient was able to verbalize satisfaction with quality and
c. Pass stool of soft or semi formed consistency without straining.
a. Administer laxatives, stool softener as indicated.
Subjective Cues: Wala pa kayo kou tarong nga tulog ku sige ug hilak ako
Disturbed sleep pattern related to noise brought about by cry
Environment can promote or hinder sleep. The absence of
After 8 hours of nursing intervention, the patient will be able to verbalize that she
Nursing Action: Render nursing intervention to have an optimal sleep pattern.
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anak kada gabii. As verbalized by the patient. Objective Cues: Restlessness Noted Dark circles Under the eyes Frequent yawning.
of the newborn.
usual stimuli or the presence of unfamiliar stimuli can keep people from sleep. (Kozier, 2002:956)
can sleep satisfactorily. Outcome Criteria: Specifically the patient will be able to: a. Evaluate sleep patter and dysfunction a. Obtain feedback from client regarding usual bedtime, rituals, routines, number of hours of sleep, time in arising, and environme ntal needs. b. Arrange care to provide for uninterrupt ed periods for rest. a. to determine the usual sleep pattern and provide comparative baseline. (Doenges, 2004:474)
amount of sleep, and reported feelings of being rested and refreshed after waking.
b. To assist client to establish optimal sleep/rest pattern.
b. It enables patient to sleep uninterruptedly . (Doenges, 2002 :338)
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c. To have regular sleeping pattern
c. Restrict intake of caffeinecontaining foods/ fluids.
c . Caffeine may delay patients falling asleep and interfere with rapid eye movement sleep, resulting in patient not feeling well rested ( Doenges, 2002; 338) d. d. Relaxati on measure s help induce sleep. (Kozier, 2002:96 3)
d. Fall asleep within 30 to 45 minutes of going to bed
d. Provides clients desired comfort measure or sleeping aids such as appropriate positioning and supports, soft music and warm milk. e. Provide a quite peaceful environment during sleeping periods.