ASSESSMEN3.docx

8/11/2019 ASSESSMEN3.docx

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ASSESSMENT NURSINGDIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective

Pt states that she is in pain in her ―privatearea .

Objective

Pt states her pain level is7 out of 10 on the painscale.

Insertion of foleycatheter

Diagnosis of UTI

Pt demonstratesgrimaces and guarding

Acute Pain r/t UTIdiagnosis

Short Term:Pt will report a

decrease in her painlevel or <4 out of10 on this shift.

*Assess pain by using the 10 point pain rating scale q4 hrs

or PRN.

*Administer medications asordered.

Single item ratings of pain intensity are valid

and reliable asmeasures of painintensity. ―Systematic ongoingassessment anddocumentation

provide direction forthe pain treatment

plan; adjustments aremade based on the

client’s response.(Ackley & Ladwig,2008, p.604)

―Pharmacologicalinterventions are thecornerstone ofmanagement ofmoderate to severe

pain. Unless

contraindicated, allclients with acute painshould receive anonopiod agent aroundthe clock. (Ackley &Ladwig, 2008, p.605)

Goal met. Pt reported adecrease in her pain

level that wasoriginally 7 out of 10.Pt was givenappropriatemedications to relievethe pain. She did notreport an increase in

pain throughout the dayand reported 2 out of10 by the end of the

shift.



*Explain to the pt the painmanagement approach that has

been ordered.

―One of the mostimportant steps towardimproved control of

pain is a better clientunderstanding of thenature of pain, itstreatment, and the rolethe client needs to playin pain control.(Ackley & Ladwig,2008, p.606)



Glomerulonephritis



Subjective Data:―I felt mutatedwith this enlargedarms and feet sinceif suffered fromthis illness, asverbalized by the

patient.

Objective Data:- +3 edema

on bothfoot

- +2 edemaon bothhands

- (+) periorbitaledema

- (+) proteinuria

- 30 ml urineoutput forthe last 8hours

- Vital signs:BP — 140/90

PR — 120 bpm

Fluid volumeexcess r/tdecreasedglomerularfiltration rate

Short termgoal:

Client willhave anincreased urineoutput of 70-80ml for the next6 hours.

Long termgoal:

Client willhave asustainedminimum urineoutput of 20 ml

per hour andmanifest lesseredema (+) 1.

Assessment: Obtain complete physicalassessment.

Monitor daily weight.

Monitor fluid intake andoutput every 4 hours.

Monitor BP and PR everyhour.

Assess for adventitious breath sounds.

Monitor laboratory valuesespecially for the proteinlevel in the urine.

Treatment:1. Maintain dietary restrictionsduring

acute phase.a. sodium

b. protein

To have baseline data onthe progress of fluidelimination through

physical appearance. To have a measurable

account on the fluidelimination.

To know progressingcondition via glomerularfiltration.

To know progression ofhypertension and basisfor further nursingintervention or referral.

To know for possible progression in the lungs.

To know the extent of protein loss which led toedema.

a. to help prevent fluid retentionvia absorption.

b. it helps prevent fast elevationof BUN level.

Helps prevent further fluidaccumulation while there is

Client had a totalurine output of 72ml 4 hours aftertheimplementation ofthe nursinginterventions.

Client had edemaof (+) 1 the secondday of nursingintervention.Patient also had anaverage of 24 mlof urine output forthe last 10 hours.



2. Maintain fluid restriction

3. Elevate extremities with pillowswhen at rest or at lying position.4. Administer diuretics as ordered.

5. Administer antibiotics as ordered.6. Administer anti hypertensive drugsas ordered.

Educative:

1. Encourage ambulation and nonstrenuous exercises.2. Teach on the importance ofelevating extremities when at rest.3. Encouraged to maintain clean andmoist skin.

4. Encouraged to stick on dietary andfluid restrictions.

decreased glumerular filtration.

Helps fluid excretion via

gravity.

Helps excrete excess fluidsthrough pharmacologicalreaction.

Fights infection and progressionof scarring.Controls hypertension as caused

by excessive fluid.

1.Helps increase blood and fluidcirculation.

2. Reinforces awareness on itseffect on fluid excretion.

3. Helps prevent skin breakdownand further infection arisingfrom the skin.

4. For client cooperation even inthe absence of any medical

practitioner.



Nephrolithiasis/Urolithiasis



S> ―masakit anglikod ko as

verbalized

O> with facial

grimace

Irritable at times

Slightly weak inappearance

With guarding

behavior

Pain scale=8/10

BP=110/80

Alteration incomfort; flank painsecondary to diseasecondition

At the end of nursingintervention the

patient will be able to

demonstrate ways

and technique on how

to reduce pain to a

tolerable level

Assessed severity of pain using pain scale

Monitor VS esp. BP

Provided comfort

measures such as

positioning

Provided diversional

activities such as listeningto music or talking to S.O.

Instructed S.O. not to

leave the patient alone

Provided therapeutic

touch

Demonstrated and

encouraged to do deep

breathing exercise

Encouraged back

tapping

For baseline data

For baseline data

To promote comfort

and relaxation

To divert focus of

attention to pain

To prevent pain

stimulation

To promote comfort

and relaxation

For pharmacologic

intervention

―Medyo nawala naung sakit ng likod ko as

verbalized

Pain scale= 6/10

BP=90/60



Avoid abrupt

movements

Provided adequate rest

and sleep periods

Administered analgesics

as ordered



Acute Renal Failure



Subjective:―Nagmamanas lang ako nunguna at ngayon naman ayminsan nahihirapan na akonghuminga … (I am onlyhaving edema before but nowsometimes I have somedifficulty in breathing...) – verbatim of client.

Objective:Easy fatigabilityWeaknessShortness of breathWeight gain as claimedAnorexiaHistory of glomerulonephritiswhen she was still a childUrinalysis showed proteinuriaHematologic lab resultsindicate decreased Hgb andHct counts.Latest blood pressure :150/100mmHgLatest respiratory rate:25 breaths/min.

Impaired GasExchangerelated to

decreased red blood cell production

and reductionin the oxygen

carryingcapacity ofthe blood

secondary todisease

process.

After 8 hours ofnursing care, theclient will be ableto show animproved gasexchange asevidenced bydecreased episodesof dyspnea/shortness of breathand improvedtolerance to simpleactivity.

-Assess client’s respiratory rate,depth and use of accessory muscles.

- Monitor vital signs and check forfluctuations in RR, PR, and BP.Presence of hypovolemia may show adrop in BP and some tachycardia.

- Assess ability and tolerance toactivity; assist client in ambulation orlimit stressful activity depending onclient’s tolerance.

-Place client in fowler’s position,elevating head while maintainingcomfort.

- Provide supplemental oxygen asindicated, i.e. O2 at 2liters per min.

-Provide a quiet non stimulatingenvironment.

-Assist in transfusion therapies asindicated.

- Provides baseline dataof client’s complainand degree ofrespiratorycompromise.- It could help assessthe client’s need for

blood transfusiontherapy.

-Assisting client andlimiting activity mayhelp reduce the oxygendemand of the body,reducing shortness of

breath episodes.- Placing client in afowler’s position assistin the proper chestexpansion.

-Supplemental oxygenaids in minimizing theincreased need of the

body for oxygen,depending onsituational requirement.- It promotes adequateresting periods for the

After 8 hours ofnursing care, thegoals were

partially met asevidenced byreduction ofepisodes ofdyspnea whenclient hadenough rest butstill complains ofshortness of

breath upongoing to the restroom even withassistance.



Chronic Renal Failure



Objective:Patient manifested: Edema Hypertension Weight gain Pulmonary

congestion (SOB,DOB)

Oliguria Distended jugular

vein Changes in mental

status

Fluid VolumeExcess R/T decreaseGlomerular filtrationRate and sodiumretention

Short Term :After 4-8 hours ofnursing interventions,

patient willdemonstrate

behaviors to monitorfluid status andreduce recurrence offluid excess

Long Term :After 3 days ofnursing interventionthe patient willmanifest stabilizefluid volume AEB

balance I & O,normal VS, stableweight, and free fromsigns of edema.

1. Establish rapport

2. Monitor and recordvital signs

3. Assess possible riskfactors

4. Monitor and recordvital signs.

5. Assess patient’sappetite

6. Note amount/rate offluid intake from allsources

7. Compare currentweight gain withadmission or previous

1. To assess precipitatingand causative factors.

2. To obtain baseline data

3. To obtain baseline data

4. To note for presence ofnausea and vomiting

5. To prevent fluidoverload and monitorintake and output

6. To monitor fluidretention and evaluatedegree of excess

7. For presence of cracklesor congestion

8. To evaluate degree ofexcess

9. To determine fluidretention

Short Term :The patient shall havedemonstrated behaviorsto monitor fluid statusand reduce recurrenceof fluid excess

Long Term :The patient shall havemanifested stabilizedfluid volume AEB

balance I & O, normalVS, stable weight, andfree from signs ofedema.



stated weight8. Auscultate breath

sounds

9. Record occurrence ofdyspnea

10. Note presence ofedema.

11. Measure abdominalgirth for changes.

12. Evaluate mentationfor confusion and

personality changes.

13. Observe skin mucousmembrane.

14. Change position ofclient timely.

15. Review lab data likeBUN, Creatinine,Serum electrolyte.

16. Restrict sodium andfluid intake ifindicated

17. Record I&O

10. May indicate increase influid retention

11. May indicate cerebraledema.

12. To evaluate degree offluid excess.

13. To prevent pressureulcers.

14. To monitor fluid andelectrolyte imbalances

15. To lessen fluid retentionand overload.

16. To monitor kidneyfunction and fluidretention.

17. Weight gain indicatesfluid retention or edema.

18. Weight gain mayindicate fluid retention



accurately andcalculate fluid volume

balance

18. Weigh client

19. Encourage quiet,restful atmosphere.

20. Promote overallhealth measure.

and edema.19. To conserve energy and

lower tissue oxygendemand.

20. To promote wellness.



Hemodialysis

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSUBJECTIVE:

“Nanghihina ako” asverbalized by thepatient.

OBJECTIVE:

Loss of weight Restlessness Weakness

V/S taken asfollows

T: 36.8 ˚C P: 73R: 18BP: 110/ 80

Risk for deficient fluidvolume. Risk factor mayinclude ultrafiltration, fluidrestriction and actual bloodloss such as systemicheparinization ordisconnection of the shunt

After 8 hours ofnursinginterventions, thepatient will maintainfluid balance asevidenced by stablevital signs, goodskin turgor, moistmucousmembranes,absence ofbleeding, andappropriate weight.

Independent Measure all

sources ofintake andoutput. Havepatient to keepa diary.

Weigh daily aswell as beforeand afterdialysis run.

Monitor vitalsigns duringdialysis.

Ascertainwhetherdiuretics andantihypertensives are to bewithheld.

Verify continuityof shunt or

Aids in evaluatingstatus, especially whencompared with weight.

Weight loss overprecisely measuredtime is a measure ofultrafiltration and fluidremoval.

Hypotension,tachycardia, and fallinghemodynamicpressures suggestsvolume depletion.

Dialysis potentiateshypotensive effects ifthese drugs have beenadministered.

Disconnected shunt oropen access permitsexsanguination.

Minimizes stress on

cannula insertion siteto reduce inadvertentdislodgement andbleeding from site.

Maximizes venousreturn if hypotensionoccurs.

After 8 hours of nursinginterventions, the patientwas able to maintain fluidbalance as evidenced bystable vital signs, goodskin turgor, moistmucous membranes,absence of bleeding, andappropriate weight.



access catheter.

Apply externalshunt dressing.Permit nopuncture ofshunt.

Place patient ina supine ortrendelenburgposition, asnecessary.

Collaborative Monitor

laboratorystudies asindicated.

Reduce rate ofultrafiltrationduring dialysis,as indicated.

To monitor closely toprevent futurecomplications.

Reduces the amount ofwater being removedand may correcthypotension orhypovolemia.



Peritoneal Dialysis



O:>cyanosis>rr- 10bpm>shallow

breathing

Risk forIneffectiveBreathingPattern r/tinflammatory

process

After 8 hours ofnursing interventionthe client will displayan effectiverespiratory patternwith clear breathsounds, ABGs within

patient’s normalrange.

1. Monitor respiratoryrate/effort. Reduce infusionrate if dyspnea is present.

2. Auscultate lungs, notingdecreased, absent, oradventitious breath sounds,e.g.,crackles/wheezes/rhonchi.

3. Note character, amount, andcolor of secretions.

4. Elevate head of bed or have patient sit up inchair. Promote deep-

breathing exercises andcoughing

5. Review ABGs/pulseoximetry and serial chest x-rays.

6. Administer supplemental O2as indicated.

7. Administer analgesics asindicated.

1. Tachypnea, dyspnea,shortness of breath, andshallow breathingduring dialysis suggestdiaphragmatic

pressure from distended peritoneal cavity or mayindicate developingcomplications.

2. Decreased areas ofventilation suggest

presence of atelectasis,whereas adventitioussounds maysuggest fluid overload,retained secretions, orinfection.

3. Patient is susceptible to pulmonary infections asa result of depressedcough reflex andrespiratoryeffort, increasedviscosity of secretions,as well as alteredimmune response andchronic/debilitatingdisease.

4. Facilitates chest

After 8 hours ofnursingintervention theclient displayed aneffectiverespiratory patternwith clear breathsounds, ABGswithin patient’snormal range.



expansion/ventilationand mobilization ofsecretions.

5. Changes in Pao2 andPaco2 and appearanceof infiltrates/congestionon chest x-ray suggestdeveloping pulmonary

problems.6. Maximizes oxygen for

vascular uptake, preventing/lesseninghypoxia.

7. Alleviates pain, promotes comfortable breathing, maximalcough effort.



BloodPressure:130/90mmHg

Collaborative

1. Catheterize forresidual urine and leaveindwelling catheter asindicated.

2. Administermedications as indicated.

term. Antibiotics aregiven to combatinfection.



Nasopharyngeal Cancer



Subjective:―Masaki tanglalamunan ko lalo na

pag nagsasalita. Asverbalized by theclient.

Objective: Dyspnea Restlessness Use of accessorymuscle Cough Nasal flaring

Prolonged expiratory phase

Ineffective airwayclearance r/ttissue necrosislocated in nasalarea AEBdyspnea,restlessness, useof accessorymuscle, cough,and nasal flaring.

After 3 hours of NI, pt will be able to verbalizeunderstanding of cause andtherapeutic managementregimen and demonstrate

behaviors to improve ormaintain clear airway.

Establish rapport

Position head to facilitateairway

Elevate head of bed

Encourage deep-breathingand coughing exercise

Increase fluid intake

Supportreduction/cessation ofsmoking

To get the trust of the pt. To open or maintainopen airway in at-restor com promisedindividual To take advantage ofgravity decreasing

pressure on thediaphragm andenhancing drainage To maximize effort inexpectoratingsecretions Hydration can helpliquefy viscoussecretions and improvesecretion clearance

To improve lungfunction

After 3 hours of NI, pt was able toverbalizeunderstanding ofcause andtherapeuticmanagementregimen anddemonstrate

behaviors toimprove ormaintain clearairway.



Ovarian Cancer



Subjective:

―Mabilis akongmapagod ngayon,tingin kokailangan ko pa ngsapat na lakas paramagawa ko yungmga karaniwangginagawa ko asverbalized by theclient.

Objective:

Limitedmovement

Activityintolerancerelated togeneralizedweaknesssecondary tounderlyingdisease process

After 6 hours ofnursingintervention, theclient will stateunderstanding ofand willingness tocooperate inmaximizingactivity level

Independent:

1. Note presence of factorscontributing to fatigue

2. Evaluate current limitations

3. Have patient perform self-careactivities. Begin slowly and increasedaily, as tolerated.

4. Provide emotional support andencouragement

5. Note treatment-related factors,such as side effects/interactions ofmedications

6. Adjust activities

7. Plan care with rest periods betweenactivities

8. Assist with activities and provideclient’s use of assistive devices

- To identify causative factors

- Provides comparative baseline

- Activities will help patientregain health

- To help improve patient’sself-concept and motivation to

perform activities of dailyliving.

- To identify precipitatingfactors

- To prevent overexertion

- To reduce fatigue

- To protect client from injury

After 6 hours ofnursingintervention,goal met, asevidence by client’sable to stateunderstanding ofand willingness tocooperate inmaximizing activitylevel



9. Encourage client to maintain positive attitude; suggest use ofrelaxation techniques

- To enhance sense of well- being



Retinoblastoma



Objective:-Eye is opened inhorizontal plane

-Cloudy cornea thatmeasures 10mm x9mm and isedematous

-Anterior chamber isobliterated

-Vitreous cavitycontains granularwhite material

-Sclera is thickenedand fibrotic

-Choroid and focalarea of sclera arediffusely invaded bytumor

DISTURBEDSENSORYPERCEPTIONrelated toaltered status ofsense organ(eyes)secondary toretinoblastoma

Goal:After 8 hours of nursingintervention, the patientwill be able tocompensate for sensoryimpairments.

Independent:Assess ability to speak, hear, interpretand respond to simple commands.

Evaluate sensory awareness: stimulusof hot/cold, dull/sharp, smell, taste,hearing, and location/function of body

parts.

Determine response to painful stimuli.

Provide means of communication and promote stable environment withcontinuity of care by same personnelas much as possible. And reorient to

person, place, time and events, asnecessary.

Avoid isolation of client, physically oremotionally.

Interpret stimuli and offer feedback.

To obtain anoverview ofclient’s mentaland cognitivestatus and abilityto interpretstimuli.

To assess degreeof impairment.

To note whetherresponse isappropriate tostimulus,immediate ordelayed.

To promotenormalization orresponse tostimuli.

After 8 hours of nursingintervention, the patientwas able to compensatefor sensoryimpairments.



Speak to visually impaired clientduring care.

Provide tactile stimulation as care isgiven.

Provide safety measures as needed.

Position doors and furniture so theyare out of travel path for client withimpaired vision.

Collaborative:Collaborate with and involve otherhealth team members in providingrehabilitative therapies andstimulating modalities

To preventsensorydeprivation andlimit confusion.

To assist client toseparate realityfrom fantasy andaltered

perception.

To provideauditorystimulation and

prevent startlereflex.

Touching is animportant part ofcaring and a deep

psychologicalneedcommunicating



presence.

To prevent injuryand complication.

To aid inmaintaining

balance.

To achievemaximal gains infunction and

psychosocial well being.



Oral Cancer



O: PHYSICALEXAMINATION- Vital signs:

RR – 20 breaths/min BP – 120/70mmHg, Larm

PR- 67/min, L arm,radial

T-35.9^C- Skin graft over mouthextending to neck- Mark from tracheostomy,midline, neck, 0.5 cmdiameter- Lateral mouth erosions- Decreased intake of food,difficulty swallowing(blenderized feeding)

LABORATORY RESULTS(02/14/11) Hgb: 84 g/L LOWRBC: 2.80 10^12/L LOWHCT: 0.249% LOW

WBC: 6.88 10^9/L NORMAL Neutrophil 0.745 HIGHLymphocyte = 0.112 LOWMono = 0.103 NORMAL

Risk for Infectionr/t compromisedimmune defensessecondary to cancer

By the end ofthe nursingintervention,the client will:

1. Not developfurther breaksfrom primarydefenses

1. Maintain strictasepsis when

performing procedures toclient .

2. Exercisemeticuloushandwashing

before and afterhandling patient.

3. Check presence ofinvasive devicesand monitor their

present condition.

4. Monitor vitalsigns especiallytemperature every4 hours.

5. Check incisions/wounds for signsof infection.

6. Cleanse mouth

R: Asepsis will preventclient from entry oorganisms thus, protectingher from infection.

R: Frequent, meticuloushandwashing greatlydecreases the chanced of

spreaing infection.

R: Checking of condition oflines or devices, theirduration of attachment willhelp the nurse identify

possible sources ofinfection, which she thencan remove.

R: Fever or hypothermiamay indicate presence ofinfection.

R: Skin and mucosa provide first line defenseagainst microorganisms.

By the end of the shift,the client will be able to:

1. Not acquire anyinfective organism.

2. Cleanliness andhygiene are maintainedat wound sites and bedsides.

3. Developed resistanceto infection throughtechniques



Eoso = 0.300 NORMALBaso = 0.001 NORMAL

2. Achievetimely woundhealing withno infection.

erosions, if notcontraindicated.

7. Providemeticulous skincare (cleansing

bath)

8. Assist with oralcare (Orahex) ifneeded.

9. Promote frequentand adequate fluidintake.

10. Encourage toapply lubricant(petroleum jelly)to lips and skingraft.

11. Encouragefrequent positionchanges/ambulation, coughing, anddeep breathingexercises. 12.Provide healthteaching on:

R: Ensures that wound is free from infection- causingorganisms and is kept cleanto prevent infections.

R: To prevent skinbreakdown which is a

possible way of infection.

R: Provides care if client isunable.

To liquefy secretions and facilitate expectorations to prevent stasis of body fluidsand promotes moist mucusmembranes.

R: Keeps areas moist.

R: To promote ventilationin all lung segments andaids in mobilizing

secretions to prevent pneumonia.



Testicular Cancer



Anxietyrelated to crisissituations (cancer),health change,socio-economics,the role andfunctions,form interaction ,

preparation ofdeath, separation offamilies.

After 8 hours ofnursing intervention:

Clientscan relieve anxiety.

Relax and beable to see himselfobjectively.

Demonstrateeffective coping andable to participate intreatment.

Determine the client'sexperience prior to the illness.

Provide accurateinformation about prognosis.

Give the client anopportunity to express anger,fear, confrontation. Givereasonable information to theemotions and expressions

accordingly. Explain the treatment,

the purpose and side effects.Help clients prepare fortreatment.

Note the ineffectivecoping such as lack ofsocial interaction, helpless.

Encourage todevelop interaction with thesupport system.

Provide a quiet andcomfortable environment.

Maintain contact withclients, talk and touch with thefair.

Data about previousclient experience will

provide a basis forcounseling and avoidduplication.

Provision ofinformation to assist clientsin understanding the disease

process.

Can reduceclient anxiety.

Assist clients inunderstanding the need fortreatment and side effects.

Knowing the client'scoping patterns and exploreand resolve / providesolutions in an effort toincrease the strength indealing withanxiety.

So that clients getthe support from the nearest

person / family.

Providing theopportunity for clients to

After 8 hours of nursingintervention:

Clients relievesanxiety

Relax and ableto see himselfobjectively.

Demonstrateeffective coping andable to participate intreatment.



Throat Cancer

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONO:>difficulty ofswallowing>pain of 7 out of 10>irritability

Ineffective airwayclearance r/t to trachealobstruction and swelling

After 8 hours ofnursingintervention clientwill be able tomaintain patentairway withaspiration

prevented

Monitor respiratory rate, depth,and work of breathing.

Auscultate breath sounds,noting presence of rhonchi.

Assess for dyspnea, stridor,―crowing, and cyanosis. Notequality of voice.

Caution patient to avoid bending neck; support headwith pillows.

Assist with repositioning, deep breathing exercises, and/orcoughing as indicated.

Suction mouth and trachea asindicated, noting color andcharacteristics of sputum.

Respirations may remainsomewhat rapid, butdevelopment ofrespiratory distress isindicative of trachealcompression from edemaor hemorrhage

Rhonchi may indicateairway obstruction/accumulation of copiousthick secretions.

Indicators of trachealobstruction/laryngealspasm, requiring promptevaluation andintervention.

Reduces likelihood oftension on surgicalwound.

Maintains clear airwayand ventilation. Although―routine coughing is notencouraged and may be

painful, it may be neededto clear secretions.

After 8 hours ofnursingintervention clientwas able tomaintain patentairway withaspiration

prevented



Check dressing frequently,

especially posterior portion.

Investigate reports of difficultyswallowing, drooling of oralsecretions.

Keep tracheostomy tray at bedside.

Provide steam inhalation;humidify room air

Assist with/prepare for procedures, e.g.:Tracheostomy;Return tosurgery.

Edema/pain may impair patient’s ability to clearown airway.

If bleeding occurs,anterior dressing mayappear dry because blood

pools dependently.

May indicateedema/sequestered

bleeding in tissuessurrounding operative site.

Compromised airway maycreate a life-threateningsituation requiringemergency procedure.

Reduces discomfort ofsore throat and tissueedema and promotesexpectoration ofsecretions.

May be necessary tomaintain airway ifobstructed by edema ofglottis or hemorrhage.Mayrequire ligation of

bleeding vessels.



Pancreatic Cancer

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONS: ― Medyokinakabahan

siyempre. I think thatis normal. We do notknow what to expect.

― I just use prayers tocalm down .

― Client cried whenthe nun said that shecould not administerthe holy sacrament theday of her surgery. ”

O: BP = 120/60RR = 24/minPR = 64/min

(+) sleep disturbances,

weakness, faintness,fatigue

Gastroscopy results:Post-endoscopicdiagnosis: duodenalmass probablymalignant, 1 ° VSinfiltration, hiatal

Anxiety (moderate) relatedto actual or perceivedthreat to biologic integritysecondary to invasive

procedures

Anxiety is a state ofmentaluneasiness,apprehension,dread, orforeboding or afeeling ofhelplessnessrelated to animpending oranticipatedunidentifiedthreat to self orsignificantrelationships.

Anxiety on theunkniwn,especially

surgery, isnatural andcommon.

Moderate painincreases in thearousal state toa point wherethe person

GOAL:At the end of thenursingintervention, Mrs.Xxx will relate anincrease in

psychological and physiologiccomfort.

OBJECTIVES:

After the nursingintervention, Mrs.Xxx will:

1. Explain theimportance of

preoperativelaboratory tests in

her own words.

2. Verbalizeunderstanding of

bowel and skin preparation andneed to remove allmake-up and

jewelry prior to

The student nurse will:

1. Explain the need for preoperative laboratorytests

R: The moreinformation a clienthas, the more she isreassured.

2. Discuss bowel andskin preparation andthe need to remove all

jewelry, nail polish,make-up, etc. prior tosurgery.

R: Discuss preparations toempower client.

3. Briefly discuss the procedure to be doneand what the clientcould expect from it.


After the nursing intervention,Ms. xxx will:

1. Explain the importance of preoperative laboratory testsin her own words.

2. Verbalize understanding of bowel and skin preparationand need to remove all make-up and jewelry prior tosurgery.

3. State her ownunderstanding of the

procedure to be done andwhat could be expected

4. State the need forrestriction food and oral fluids

for at least 8 hours prior tosurgery.

5. Demonstrate ambulation,leg exercises, deep breathingand coughing exercises.



hernia expressesfeelings oftensions,nervousness orconcern.

SOURCE:

Kozier, B., Erb,G., Berman,A. &Snyder, S.(2004).Fundamentals of nursing(7 th ed).Philippines:PearsonPrentice Hall

surgery.

3. State her ownunderstanding of the

procedure to bedone and whatcould be expected

4. State the need forrestriction food andoral fluids for atleast 8 hours priorto surgery.

5. Demonstrateambulation, legexercises, deep

breathing andcoughing exercises.

4. Explain the need forrestriction of food andoral fluids for at least8hours prior to surgery.


5. Demonstrate theneed for ambulation,leg exercises, deep

breathing and coughingexercises.

R: This arenonpharmacologicalmethods used to lessenanxiety.

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