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CUES

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOAL & OUTCOME CRITERIA After 2 hours of nursing interventions. The patients pain will be alleviated. OUTCOME CRITERIA: Specifically the patient will be able to: 1. Report alleviation of pain with a pain scale of 2 out of 10. 2. Reestablish comfort. 3. Verbalize relief from pain by the use of prescribed analgesic. 4. Use recreational activity to distract from pain.

NURSING ACTIONS & NURSING ORDERS

RATIONALE

EVALUATION

Subjective: Mga usa ka adlaw pagkahuman nakog opera, nakabati kog kasakit og kangul-ngol na dili nako masabtan. As verbalized by the patient. Objective: Pain scale: 10/10 as 1 is the lowest and 10 is the highest O- right after surgical operation L right and left lower quadrant of

Acute pain secondary to surgical incision.

Specialized pain receptors or nociceptors can be excited by mechanical stimuli (e.g trauma to body tissue from surgery). During the transduction phase, noxious stimuli with the potential to injure tissue trigger the release of biochemical mediators (e.g prostaglandins, histamine) that sensitize nociceptors. (Kozier, 2008)

After 2 hours of nursing interventions, the goal was Met as Evidence-d by:

INDEPENDENT Assess pain characteristics. Assessment of the pain experience is the first step in planning pain management strategies. (Gulanick, M et al, 2007) 1. The patient reported alleviation of pain with the scale 2 out of 10. 2. Verbalized comfort. 3. Verbalized relief of pain by the use of analgesic. 4. Able to used recreational activity to distract from pain.

Position the client in a comfortable way.

To alleviate discomfort. (Doenges, M. et.al, 2007)

the abdominal cavity C- radiating all over the body started after surgery and didnt stop R- none T- physician induced a pain reliever S- 10/10 -guarding behavior -grimaced face

5. Do deep breathing exercise.

Instruct relaxation exercise.

Techniques are used to bring about a state of physical and mental awareness and tranquility. (Gulanick, 2007) Relaxations techniques help reduce skeletal muscle tension, which will reduce the intensity of pain. (Kozier & Erbs, 2008) Prompt responses to complaints may result in decreased anxiety towards the patient. (Gulanick, 2007)

5. Utilized the deep breathing technique as an exercise to relieve pain.

Teach the patient to do proper deep breathing.

Respond immediately to complaints of pain.

DEPENDENT Give analgesic as prescribed. Pain medications are effective therapy. (Gulanick, 2007)

COLLABORATIVE Instruct the S.O to assist the patient in change positioning. To have knowledge on ways to help the patient meet the needs (Doenges, 2007) Individualizing the pain relieving regimen recognizes individual differences in pain perception and provides more effective control.

Collaborate with the physician for patients optimal pain management

Nonsteroidal antiinflammatory drugs are used alone for mild pain and in combination with opioids for moderate to severe pain. (Gulanick, 2007

CUES

NURSING DIAGNOSIS Risk for deficient fluid volume secondary to NPO (nothing per orem) status.

SCIENTIFIC BASIS Because water is lost while electrolytes particularly sodium are retained, the serum sodium osmolality and serum sodium levels increase. Water is drawn into the vascular compartment from the interstitial space and cells, resulting in cellular dehydration (Kozier, 2008)

Subjective: Nag-uga na akong tutunlan unya nangapaksit na akong ngabil. As verbalized by the patient.

GOAL & OUTCOME CRITERIA After 4 hours nursing intervention the patient will be able to manifest fluid balance. OUTCOME CRITERIA: Specifically the patient will be able to: 1. Gain the lost water of the body. 2. Manifest good skin turgor. 3. Manifests moisten mucous membran es.

NURSING ACTIONS & NURSING ORDERS

RATIONALE

EVALUATION

After 4 hours of nursing interventions, the goal was Met as evidenced by: INDEPENDENT 1. Monitor vital signs. Tachycardia may indicate fluid volume deficit. (Gulanick, 2007) 1. Gained the loss fluids and electrolyte in the body.
2. Manifeste

Objective: Dry lips Poor skin turgor NPO status Weak looking

2.

Monitor intake Output of and output 30ml/hr level. indicates adequate hydration. (Gulanick, 2007) Increasing thirst and a coated tongue occur with fluid volume

d good skin turgor.


3. Manifeste

Sunken eyeballs

3. Check mucous membranes and skin turgor.

d moistened buccal mucosa and lips. 4. Returned pulse rate from 109

Dry mucous membrane

Pulse rate: 109 beats per minute

4. Return pulse rate from 109bpm to 70bpm. 5. Relieve from the increase IV fluid. 4. Apply wet cotton balls to crack lips.

deficit. (Gulanick, 2007)

bpm to 70bpm. 5. Relieved from increase IV fluid administer ed.

Prevents dry lips that may cause bleeding. (Gulanick, Klopp, 2007)

5. Provide oral hygiene.

NPO status will cause a dry, sticky mouth (Gulanick, 2007)

DEPENDENT

1. Administer IV fluid as ordered.

IV fluids are often prescribed to correct fluid volume deficit

and maintain fluid balance post operatively. (Gulanick, 2007)

2. Provide oral fluids as prescribed.

Oral fluids are usually restricted until peristalsis returns. (Gulanick, 2007)

COLLABORATIVE 1. Teach the patient and significant others for the interventions to prevent future episodes of inadequate intake. Patients need to understand the importance of drinking extra fluid during bouts of diarrhea, fever and other conditions

causing fluid deficits (Gulanick, 2007)

2. Collaborate with medical therapist for the hemoglobin and hematocrit test.

Dropping Hgb and Hct may indicate internal bleeding. (Gulanick, 2007)

CUES

NURSING DIAGNOSIS Hyperthermia secondary to anesthesia.

SCIENTIFIC BASIS The hypothalamic integrator, the center that controls the core temperature, is located in the hypothalamus. When hypothalamus sensors detect heat, they send out signals intended to reduce the temperature that is to decrease heat production and increase heat loss. Thus, when the warmth

Subjective : Init kayo akong lawas. As verbalized by the patient. Objective: Temperatu re: 38.5C Pulse rate:109 beats per minute Warm to touch Weak looking

GOAL & OUTCOME CRITERIA After 2 hours of nursing care the patient will be able to manifest decrease temperature in expected range. Specifically the patient will: 1. Experience decrease body temperature from 38.5 37.5C. 2. Manifest heat loss to decrease body temperature. 3. Will be relief from

NURSING ACTIONS & NURSING ORDERS

RATIONALE

EVALUATION

After 2 hours of nursing intervention, the goal was Met as evidenced by: 1. The patient reported alleviation of temperature. Vital signs provide more accurate indication of core temperature. (Gulanick, 2007)

INDEPENDENT 1. Monitor vital signs every 2 hours, as appropriate.

2. Manifested decrease temperature through thermometer measurement

2. Measure intake Fluid and output. resuscitation may be

3. Relieved from antipyretic medication.

Restlessne ss Hematocri t: 33.6(low) normal values (37- 47%)

sensitive receptors in the hypothalamus are stimulated, the effectors system sends out signals that initiate sweating and peripheral vasodilatation. (Kozier, 2008)

the prescribed antipyretic medication. 4. Will be able to utilize tepid sponge bath. 5. Achieve comfort in rest.

necessary to correct dehydration, the patient who is significantly dehydrated is no longer able to sweat, which allows for evaporative cooling. (Gulanick, 2007)

4. Relieved from the use of tepid sponge bath. 5. Achieved comfort in rest.

3. Reduce Increases body physical temperature. activity to limit ( Kozier, 2008) heat production.

4. Cover the patient with only one sheet or remove the excess clothing.

This reduces and lowers body heat and increase evaporative cooling. (Kozier, 2008)

5. Provide tepid sponge.

These measure help promote cooling and lower core temperature. (Gulanick, 2007)

DEPENDENT 1. Administer antipyretic as ordered. Temperatures above normal range for extended periods can cause cellular damage, delirium, and convulsions. (Gulanick, 2007)

2. Administer replacement fluids and electrolytes to support.

Sodium loses occur with profuse sweating and accidental hyperthermia.

COLLABORATIVE 1. Help client and significant others to develop simple and convenient schedule for taking medications. Individualizing schedule to fit clients personal habits may take it easier to get in the habit. (Kozier, 2008)

2. Health teaching the patient and significant others promote wellness and prevent further health problem.

To know and help the client to implement the procedure simply. (Pillitteri, 2007)