PLANNING INTERVENTION & RATIONALE EVALUATION S:
>“Masakit ang tahi ko sa may puson.”
Pain Scale: 10/10 O: pertains to the period of time after surgery. It begins with the patient’s
emergence from anesthesia and continues through the time required for the acute effects of the anesthetic and the patient will verbalize decreased in pain to a
tolerable state.
From a pain scale of 10 to 2.
>Build rapport with the patient R: This is to gain trust by the patient, thus making working relationship comfortable for both the nurse and the patient.
>Place ice pack at the incision site.
R: To reduce the pain and to prevent hemorrhage by keeping the fundus contracted.
>Encourage the patient to do breathing exercises.
R: This will promote good oxygenation, therefore promote good tissue perfusion.
>Provide emotional support by
encouraging the patient to verbalize what she feels.
R: This is to increase patient’s self-worth.
>Assist the patient when turning side to side.
R: The client is still weak and needs assistance by the nurse. Turning side to side every 2 hours promote lung
expansion and it prevents complications like pressure ulcers and aspiration pneumonia.
>Administer analgesics as ordered by the physician.
R: To eradicate, if not, reduce/decrease the pain.
From a pain scale of 10 to 2.
AEB:
a.) Absence of grimace b.) Normal
respiration.
RR:17cpm
Date: August 28, 2009
CUES SCIENTIFIC
EXPLANATION
NURSING DX
PLANNING INTERVENTION & RATIONALE EVALUATION S: Ø
O:
>with surgical incision at the lower abdomen
>inability to sit
>difficulty turning discomfort felt by the client after the anesthesia has subsided causes pain and will lead
decreased client’s tolerance to the patient will be able to
gradually increase mobility.
>Build rapport with the patient R: This is to gain trust by the patient, thus making working relationship comfortable for both the nurse and the patient.
>Assist patient in turning side to side every 2 hours.
R: Turning side to side is important to promote lung expansion and to prevent
complications like pressure ulcers and aspiration pneumonia.
>Provide emotional support by
encouraging the patient to verbalize what she feels.
R: This will increase the patient’s self-worth.
>Instruct the patient to do breathing exercises.
R: This will help alleviate the pain and will promote good oxygenation, therefore promote good tissue perfusion.
>Administer analgesics as ordered by the physician.
R: To eradicate, if not, reduce/decrease the pain.
After 30 minutes of proper nursing
intervention, the patient will be
able to gradually increase mobility by turning side to side.
AEB:
a.) Absence of grimace b.) Ability to
turn side to side with minimal assistance.
34
DATE CUES SCIENTIFIC EXPLANATION
NURSING DX
PLANNING INTERVENTION &
RATIONALE
>have no oral intake for the last 8 hours
>chapped lips
>dry mouth
>with surgical incision at the lower abdomen
>consumed 2 underpad for the last 24 hours
>weak in appearance
>restless and irritable
>pale looking
>grimace
>tachypnea: RR=24
>bradycardia: PR=56
>HCT=0.266%
>HGB=80g/L
>urine output=30 cc/hr
Heavy bleeding may double for the postpartum uterus as well as internally from blood vessels
that were not securely ligated
After 1 hour of proper
a. Patient’s blood
1. Monitor Vital signs of client’s with deficient fluid volume every 4hrs. Observe for tachycardia, tachypnea, decreased pulse pressure first, then hypotension, decreased pulse volume, and
increase/decrease body temperature.
®Decrease pulse pressure is an earlier indicator of shock than is the systemic blood pressure. Decrease
intravascular volume results in hypotension and decreased tissue oxygenation. The temperature will be decreased as a result of decreased metabolism, or it may be increased if there is a infection or hypernatremia.
2. Advise client to have frequent oral hygiene, at least twice a day.
®Oral hygiene decreases
After 1 hour of proper nursing
intervention, the patient will
maintain fluid balance in a
functional level as evidenced by:
a. Patient’s blood pressure is
100/60 mmHg or higher b. Pulse remains
between 60 and 100 bpm c. Scant to no
>Capillary refill=3sec unpleasant taste in the mouth and allows the client to respond to the sensation of thirst.
Collaborative
3. Encourage patient to drink prescribed fluid amounts
®This provides water for replacement of intravascular or intracellular volume as necessary.
4. Hydrate the client with ordered intravenous solution
®Intravenous route is one of the fastest ways to deliver fluids and medications throughout the body.
5. Maintain Patent IV access, set an appropriate infusion flow rate and administer at constant rate as ordered.
® Isotonic IVF such as 0.9%
Normal Saline or Lactated Ringer’s allow replacement of Intravascular volume.
36
DATE CUES SCIENTIFIC EXPLANATION
NURSING DX
PLANNING INTERVENTION &
RATIONALE
EVALUATION August
29, 2009
S: “Hindi ko magalaw ang paa ko.”
O:
-Weak in appearance -Pale
-With limited movements -Difficulty
raising/flexing the legs -Weak peripheral pulses -Capillary refill = 3seconds
Because a woman’s abdominal muscles are lax from the stretching that occurred during pregnancy,
abdominal contents tend to shift forward and put pressure on
the suture line when she is sitting or
standing, causing pain and refill of less than 5
1. Assist patient in turning from side to side every 1-2 hours
®Turning helps in venous stasis, thrombophlebitis, pressure ulcer formation and
respiratory complication.
2. Assist client in extremity exercise.
® Helps to prevent circulatory problem by facilitating venous return to the heart.
3. Early ambulation should be encouraged whenever
appropriate.
® Early ambulation are a woman’s best safeguards against lower extremity circulatory problems
4. Encourage deep breathing and coughing exercise
® This promotes optimal
After 1 hr of proper nursing
intervention, the client will maintain a capillary refill of less than 5 seconds and will not report of calf pain, redness, edema, or areas of warmth on lower extremities
37
lung ventilation and perfusion.
5. Ensure that bedcovers must be loose enough
® Permits free movements of the toes and feet
38
Assessment Diagnosis Scientific Explanation
Planning Interventions Rationale Evaluation
S: Ø O:
• blood loss-consumed 1
• Restless and irritable
Due to large amounts of blood loss, there
are possible conditions that may occur, and patient with
hemorrhage have altered level of consciousness.
Within 2 hours of proper nursing interventions, the patient will have decreased risk for injury.
Monitor vital signs every 15 minutes
Assist the client in a comfortable
Encourage the client to verbalize her feelings and worries.
Increase
To identify if there are changes in the normal ranges and to monitor if interventions have helped normalized the client’s status.
To promote lung expansion and facilitate gas exchange.
To determine the other signs and symptoms felt by the client and
to know the appropriate nursing
interventions to be done.
Within 2 hours of proper nursing interventions, the patient was able
to have a decreased risk for injury.
39
frequent observation , and if possible, stay
with the client and enforce security measures (e.g Raise side rails)
Encourage the client to have bed rest.
Advise the client to increase fluid intake.
Administer medications as prescribed.
To prevent the client from accidentally falling or other cause of injury.
To conserve energy and feel relaxed.
To replace lost fluid and electrolytes.
To facilitate faster healing and
management.
40
41
Subjective Objective Analysis Planning Implementation Evaluation
Ø • blood
• Restless and irritable
Within 2 hours of proper nursing
interventions, the patient will have
decreased risk for injury.
Monitored vital signs every 15 minutes
Assisted the client in a comfortable position
particularly in Semi-Fowler’s or High Fowler’s position.
Encouraged the client to verbalize her feelings and worries.
Increased frequent
observation , and if possible, stay with the client and enforce security measures (e.g Raise side rails)
Encouraged the client to have bed rest.
Advised the client to increase fluid intake.
Administered medications as prescribed by the physician.
After 2 hours of proper nursing interventions, the patient was able to have a decreased risk for injury.
C. Implementation
1. Medical Management
i. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy etc.
42 Medical
Management/Treatm ent
Date Ordered/ Date Taken/
Given Date Changed/ Date
Discontinued
General Description Indication/s, Purpose/s Client's reaction to the treatment
IV Therapy
1L LRS (isotonic) with oxytocin regulated at 15 gtts/min
1L D5NM
(hypertonic) regulated at 30 gtts/min
1L D5LRS
(hypertonic) regulated at 30 gtts/min
1L D5NM
(hypertonic) with 1 amp Moriamin regulated at 30 gtts/min
Started on August 27, 2009, discontinued on the same date
August 27, 2009-August 28, 2009
Started on August 28, 2009 discontinued on the same date
August 28, 2009- august 29, 2009
IV Therapy is the giving of liquid directly into a vein.
IV Therapy is usually performed for fluid volume maintenance, fluid volume replacement, medication administration, blood administration, total parenteral nutrition and
serves as an emergency line
The patient did not reported pain in the IV site
Prior:
> understand why the therapy is needed.
> determine potential outcomes for the client
> understand the fluid and electrolyte and acid base status of the client
> provide an explanation to the client and gain cooperation
> select the appropriate IV set
During:
> assess the following:
a. right intravenous fluids infusing b. right intravenous fluids for the client
c. date on the tubing
d. right rate according to the rate prescribed and the clients condition
e. absence of kinks in the tubing that could result in occlusion of the fluid flow f. date on the intravenous access device
g. insertion site and vein access for evidence of pain, redness, warmth, or coolness, and swelling
After:
> discard the administration set accordingly
>document relevant data.
43
Prior:
>determine the need for oxygen therapy, and verify the order for the therapy.
>perform a respiratory assessment to develop baseline data if not already available.
>inform the client and support people about the safety precautions connected with oxygen use such as:
a) avoiding materials that generate static electricity, such as woolen blankets and synthetic fabrics.
b) avoiding the use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone.
> provide an explanation to the client and gain cooperation.
>assist the client to a semi-Fowler’s position.
>set up the oxygen equipment and the humidifier
44 Medical
Management/Treatm ent
Date Ordered/ Date Taken/
Given Date Changed/ Date
Discontinued
General Description Indication/s, Purpose/s Client's reaction to the treatment
Oxygen Therapy 2 Lpm for 3 hours via nasal prong
August 27, 2009
Oxygen therapy is any procedure in which oxygen is
administered to a patient to relieve hypoxia.
Clients who have difficulty ventilating all areas of their lungs, those whose gas exchange is impaired, or people who have heart failure may require oxygen therapy to prevent hypoxia.
The patient tolerated the administered oxygen and
verbalized relief from DOB
During:
>check that the oxygen is flowing freely from the tubing. There should be no kinks in the tubing, and the connections should be airtight. There should be bubbles in the humidifier as the oxygen flows through. Feel the oxygen at the outlets of the cannula.
>monitor the level of water in the humidifier.
>set the oxygen at the flow rate ordered.
>if the cannula will not stay in place, tape it at the sides of the face.
After:
>report significant deviation such as tracheal irritation and coughing, dyspnea, and decreased pulmonary ventilation.
45
Prior:
> Determine the most appropriate method of catheterization based on the purpose and any criteria specified in the order such as total amount of urine to be removed and size of catheter to be used.
>use an indwelling catheter if the bladder must remain empty or continuous urine measurements/collection is needed.
> Assess the client’s overall condition. Determine if the client is able to cooperate and hold still during the procedure and if the client can be positioned supine with head relatively flat.
> Determine when the client last voided or was last catheterized.
46 Medical
Management/Treatm ent
Date Ordered/ Date Taken/
Given Date Changed/ Date
Discontinued
General Description Indication/s, Purpose/s Client's reaction to the treatment
Urinary
Catheterization
August 27, 2009-August 28, 2009
Urinary Catheterization is the introduction of a catheter through the urethra into the urinary bladder
Indications of urinary catheterization includes relief from discomfort due to bladder distention or to provide gradual decompression of a distended bladder, to empty the bladder
completely prior to surgery, to facilitate accurate measurement of urinary output for critically ill clients whose outputs need to be monitored hourly, to prevent urine from contacting an incision after perineal surgery.
The client didn’t verbalize any discomfort and have adequate (>30cc/hr), amber colored urine output.
>Percuss the bladder to check for fullness or distention.
During:
>Ensure that there are no obstructions in the drainage. Check that there are no kinks in the tubing, the client is not lying on the tubing, and the tubing is not clogged with mucus or blood.
>Check that there is no tension on the catheter or tubing, that the catheter is securely taped to the thigh, and that the tubing is fastened appropriately to the bedclothes.
>Ensure that gravity drainage is maintained. Make sure that there are no loops in the tubing below its entry to the drainage receptacle and that the drainage receptacle is below the level of the client’s bladder.
>Ensure that the drainage system is well-sealed or closed. Check that there are no leaks at the connection sites in open systems. Apply water proof tape around the connection site of the catheter and tubing.
>Observer the flow of the urine every 2-3 hours, and note color, odor and any abnormal constituents. If sediments are present, check the catheter more frequently to ascertain whether it is plugged.
After:
>Conduct appropriate follow-up such as notifying the primary care provider the catheterization results.
> Performed a detailed follow-up based on findings that deviated from normal for the client.
> Relate findings to previous assessment data if available.
47
ii. Drugs
Name/s of drugs (generic and brand
name)
Date ordered/
Date taken/
Date changed
Route of administration &
dosage &
frequency of administration
Mechanism of action
Indication/s Purpose/s
Client’s response to medication with
actual side effect
Generic Name:
Cefuroxime Sodium
August 27-28, 2009 750 mg, IVF q 8 hours
It is a anti- infective drug and its main action is combat the preset bacteria and
inhibit increased growth.
Low respiratory infections, Pharyngitis or tonsillitis
The client did not exhibit any adverse reactions from the drug
Before:
check the expiration date of the drug
check the doctor's order
assess the client's understanding about the drug
assess for skin allergies During:
Reconstitute the drug with 8 ml of sterile water.
Slowly inject the drug over 3 to 5 mins.
After:
Evaluate the client for adverse effect.
Report lack of response, persistent diarrhea or signs ad symptoms of Anemia.
48
Name/s of drugs (generic and brand
name)
Date ordered/
Date taken/
Date changed
Route of administration &
dosage &
frequency of administration
Mechanism of action
Indication/s Purpose/s
Client’s response to medication with
actual side effect
Generic Name:
Ketorolac Tromethamie
August 27-28, 2009 30 mg, IVF q 6 hours X 6 doses
Possesses anti-inflammatory, analgesics ad antipyretic.
Completely
absorbed following IM use.
Use for
management of moderate ad severe acute pain.
The client did not exhibit any adverse reactions from the drug
Before:
check the expiration date of the drug
check the doctor's order
assess the client's understanding about the drug During:
Do not mix IV ketorolac in a small volume with morphine sulfate.
The IV bolus must be given over o less than 15 sec.
After:
Monitor for adverse effect.
Report ay unusual bruising or bleeding, weight gain, swelling of feet/ ankles, increased joint pain, change in urine patterns.
49
Name/s of drugs (generic and brand
name)
Date ordered/
Date taken/
Date changed
Route of administration &
dosage &
frequency of administration
Mechanism of action
Indication/s Purpose/s
Client’s response to medication with
actual side effect
Generic Name:
Tramadol Hydrocloride
August 27-28, 2009 100 mg, TID A Centrally acting analgesic no related chemically to opiates. Precise mechanism is unknown.
Use for
management of moderate ad severe acute pain.
The client did not exhibit any adverse reactions from the drug
Before:
check the expiration date of the drug
check the doctor's order
assess the client's understanding about the drug During:
Give the IV dose slowly over a period of 2 mins or as a continuous infusion.
Oral and IV dose are therapeutically equivalent, may switch to and from the IV form wit o cage in dose as prescribed.
After:
Monitor for adverse effect.
Report immediate ay chest pain, increased SOB, or sudden weight gain.
50
Before:
check the expiration date of the drug
check the doctor's order
assess the client's understanding about the drug During:
The capsule should be taken 30 mins before eating and is to be swallowed whole.
Antacid can be administer with omeprazole
51 Name/s of drugs
(generic and brand name)
Date ordered/
Date taken/
Date changed
Route of administration &
dosage &
frequency of administration
Mechanism of action
Indication/s Purpose/s
Client’s response to medication with
actual side effect
Generic Name:
Omeprazole
August 27-28, 2009 Q 12 hours X 2 doses
Hough to be a gastric pump inhibitor and that it blocks the final step
of acid production.
By inhibiting the Hydrogen/
Potassium ATP-ase system at te
secretory surface of the gastric parietal cell.
Use for
management of active duodenal ulcer, gastric ulcer, erosive esophagitis and heartburn
The client did not exhibit any adverse reactions from the drug
After:
Monitor for adverse effect.
Report to the physician if chest pain, abdominal pain and fecal discoloration occurred.
iii. Diet
Type of Diet
Date ordered/
Date taken/
Date changed
General Description
Indication/s Purpose/s
Specific foods Taken
Client’s response to medication with
actual side effect NPO (nothing by
mouth)
August 27, 2009 A patient care instruction advising that the patient is prohibited from
ingesting food, beverages, or
medicine.
It is usually ordered whenever the patient wills
undergoes surgery or other diagnostic procedure requiring
that the digestive tract be empty.
Foods, beverages ad medicine are
prohibited.
The client strictly complied.
Before:
Explain to the client and significant others the purpose, indication and the duration of the diet.
Assist the client’s compliance ability to the diet.
During:
Advise the client to avoid foods.
Provide frequent oral hygiene
Monitor the compliance of the patient to the diet.
After:
Evaluate the effect of the diet to the client.
Report excessive weight loss.
Assess any nutritional disturbances and notify the physician.
52
Type of Diet Date ordered, Date started, Date
changed
General description
Indication/s Purpose/s
Specific Foods Taken
Client’ s response and/or response to
the diet Clear liquid diet August 27, 2009 This client provides
the client with fluid and carbohydrate but does not supply
adequate protein, vitamins, minerals, or calories
This diet is indicated for post operative patient’s first feeding when it is necessary to fully ascertain return of gastrointestinal function
Crackers
Sips of water and tea
The client strictly complied
Prior:
>assess ability to feed self and prepare meals
>determine need for special drinking cups, plates, or feeding utensils
>determine need for special drinking cups, plates, or feeding utensils