VI. A.

NURSING MANAGEMENT

IDEAL NURSING MANAGEMENT

1.

Alteration in comfort related to muscle/cellular hypersensitivity as manifested by continued uterine contractions/irritability Interventions - assess pain characteristics - accept patient's description of pain - note patient's locus of control - evaluate patient's response to to pain and medications or therapeutics aimed at relieving pain - evaluate what the pain means to the individual - assess patient's past coping mechanisms - assess patient's expectations for pain relief Rationale - to rule out worsening of underlying condition/development of complications - pain is subjective experience and cannot be felt by others - individuals with locus of control may take little or no responsibility for pain management - it is important to help patients express as factually as possible the effect of pain relief measures - the meaning of the pain will directly influence patient's response, pain will influence activity - to determine what measures worked best in the past - this will impact on their perception on the effectiveness of the treatment modality and their willingness to participate in further treatments - observations may/may not be congruent with verbal reports indicating need for further evaluation - usually altered in pain - monitor vital signs - anticipate need for analgesics or additional methods for pain relief - respond immediately to complaint of pain - eliminate additional stressors or sources or discomfort whenever possible - early intervention may decrease the total amount of analgesic required - prompt responses to complaints may result in decreased anxiety in patient - patients may experience an exaggeration in pain or a decreased ability to to tolerate painful stimuli if there are factors further stressing them

- observe nonverbal cues

- provide rest periods to facilitate comfort, sleep, and relaxation - provide comfort measures such as change of position - whenever possible, reassure that pain is time-limited and that there is more than one approach to easing pain - instruct use of relaxation exercises such as focused breathing, listening to music or socialization with others

- the patient's experiences of pain may become exaggerated as the result of fatigue - to provide nonpharmacological pain management - when pain is perceived as everlasting and unresolvable, patient may give up trying to cope with it or experience a sense of hopelessness and loss of control - to divert attention

- so relief measures may be instituted - instruct patient to report pain - to maintain acceptable level of pain - administer analgesics as indicated

2.

Activity Intolerance related to muscle/cellular hypersensitivity as manifested by continued uterine contractions/irritability.

Interventions -assess emotional/psychological factors affecting the current situation 1. -ask the patient to refrain from performing nonessential procedures 2. 3. -assist patient with ADL as indicated 4. 5. -provide positive atmosphere, while 6. acknowledging difficulty of the situation for the patient 7. -teach energy conservation techniques

Rationale -to rule out such factors might be the result if being forced into inactivity -to promote rest -to reduce energy expenditure -helps to minimize frustration and re channel energy -they reduce oxygen consumption, allowing more prolonged activity

3. Mild anxiety related to perceived or actual threat to self and fetus as manifested by increased tension, restlessness, expressions of concern, and autonomic responses (changes in vital signs).

Interventions -assess patient's level of anxiety -assess patient's coping mechanisms in handling anxiety -acknowledge awareness of patient's anxiety

Rationale -mild anxiety enhances patient's awareness and ability to identify and solve problems -assessment helps determine the effectiveness of coping strategies currently used by the patient -acknowledgement of patient's feelings validates the feelings and communicates acceptance of those feelings -the presence of a trusted person assures patient of her security and safety during a period of anxiety -patient's feeling of stability increases in a calm and nonthreatening atmosphere -helps patient identify what is reality based -to limit degree of stress -anxiety may escalate with excessive conversation, noise and equipment around the patient -utilizing anxiety-reduction strategies enhances patient's sense of personal mastery and confidence

-reassure patient that she is safe, stay with the patient if this appears necessary -maintain a calm and tolerant manner while interacting with the patient -provide accurate information about the situation -modify procedures as possible -reduce sensory stimuli by maintaining a quiet environment -assist patient in developing anxiety-reducing skills

4. Risk for infection related to ruptured amniotic membrane as manifested by leaking bag of water. Interventions -monitor white blood count -monitor for signs of infections such as purulent discharges and elevated temperature -assess nutritional status Rationale -increase WBC indicates body's efforts to combat pathogens -antibiotic therapy may be needed if pathogens are present and high fever may indicate septicemia -patient's with poor nutritional status may be anergic or unable to muster a cellular immune response to pathogens and therefore more susceptible to infection -antineoplastic agents and corticosteriods

-assess for history of of drug use/treatment

modalities that may cause immunosuppression -assess immunization status -stress proper handwashing techniques by all caregivers between therapies/patients -monitor visitors/caregivers

reduce immunocompetence -patient may not have sufficient acquired immunocompetence -a first line of defense against nosocomial infections/cross-contamination -to prevent exposure of patient -to maintain optimal nutritional status

-encourage intake of protein and calorie rich foods -to avoid bladder distention -maintain adequate hydration and catheterize if necessary -to reduce risk of ascending UTI -provide regular catheter/perineal care -administer antimicrobial drugs as ordered -these agents are toxic to the pathogen or retard the pathogen's growth -to determine effectiveness of therapy/presence of side effects -premature discontinuation of treatment when patient begins to feel well may result in return of infection

-note patient's response to the medication -emphasize necessity of taking antibiotics as directed

5. Knowledge deficit regarding condition, prognosis, treatment and self-care needs related to unfamiliarity with information Interventions Assess patient level of knowledge and ability/ desire to learn. Rationale Necessary for creation of individual instructional plan. Verbalization identifies misunderstandings and allows for clarification. Natural defense mechanism, such as anger or denial of significance of situation, can block learning, affecting pts response and ability to assimilate information. Using multiple learning methods enhances retention of material. Post MI complication of peripheral

Be alert to signs of avoidance e.g., changing subject away from information being presented.

Present information in varied learning formats, e.g., books. Stress importance of reporting

development of fever in association with diffuse/ atypical chest pain and joint pain. Stress important of follow-up care, and identify community resources/ support groups. Emphasize importance of contracting physician if chest pain, change in angina pattern, or other symptoms recur.

inflammation requires further medical evaluation/intervention. Reinforces that this is ongoing/ continuing health problem for which support/ assistance is available after discharge. Timely evaluation/ intervention may prevent complications.

6. Imbalanced nutrition less than body requirements related to disease condition Interventions Monitor food/ fluid ingested and calculate daily caloric intake. Restrict sodium/ potassium as indicated. Rationale Identifies nutritional deficits/ therapy need. These electrolytes can quickly accumulation, causing fluid retention, weakness, and potentially lethal cardiac dysrhythmias. Helpful in identifying specific needs/ strength. Useful in measuring effectiveness of nutritional and fluid support. Helps conserve energy, especially when metabolic requirements are increased by fever. May affect dietary choices and identify areas for problem solving to enhance intake/ utilization of nutrients.

Ascertain patients usual dietary pattern, likes/ dislikes. Monitor I & O and weight periodically. Encourage and provide for frequent rest periods. Investigate for nausea and vomiting, and note possible correlation to medications. Monitor frequency, volume, consistency of stools.

B.

ACTUAL NURSING MANAGEMENT

Dili nako kahimu sa akong mga kasagara na galihukon karon, as verbalized by the patient loss of ability to execute purposeful motor acts despite physical and willingness to do so inability to feed self independently inability dress self independently inability to perform toileting tasks inability to ambulate independently Self-Care deficit related to complete bed rest Short term: At the end of eight (8) hours, patient will be able to perform self care activities within level of own ability.

Long term: At the end three (3) days, the patient will be able to demonstrate techniques/lifestyle changes to meet self care needs

1. Provided assistance as necessary but avoided doing things for patient that
patient can do for self. R: The patient may become fearful and dependent. It is important for patient to do as much as possible for self to maintain self-esteem and promote recovery.

2. Maintained a supportive and firm attitude. Allowed patient sufficient time to

accomplish tasks. R: Patients need empathy and to know caregivers will be consistent in their assistance.

3. Provided positive feedback for efforts and accomplishments.

I R: Enhances self worth, promotes independence, and encourages patient to continue endeavors.

4. Placed patient in optimal position for feeding.

R: This reduces energy expenditure.

5. Provided frequent assistance as needed with dressing.

R: To prevent the patients condition from being compromised.

6. Assisted patient with completing toileting tasks such as changing patients

diapers R: To assist patient in performing self care activities to promote elimination until patient is able to regain independent control of this function as recovery progresses.

7. Assisted and encouraged good grooming habits.

R: Enables patient to manage for self, enhancing independence and selfesteem.

wala ko kabalo nga nibuto na diay akong panubigon as verbalized by the patient request for information leaked bag of water vital signs taken as follows:

Knowledge deficit regarding condition, prognosis, treatment and self-care needs related to unfamiliarity with information Short term: At the end of eight (8) hours, patient will verbalize understanding of condition/prognosis and potential complications,

Long term: At the end three (3) days, the patient will initiate necessary lifestyle changes

1. Discussed specific pathology and individual potentials. R: Aids in establishing realistic expectations and promotes understanding of current situation and needs

2. Instructed patient on the importance of improving mobility and preventing joint deformities such as changing positions every 2 hours and importance of rehabilitation programs R: Correct positioning prevent contractures; measures are used to relieve pressure and to promote venous return and preventing edema and promote recovery 3. Assisted patient with nutrition such as emphasizing importance of soft diet and proper positioning while eating such as semi-fowlers position R: Soft diet was emphasized to prevent aggravating the patients heart condition. Proper positioning was instructed to prevent aspiration.

4. Emphasized to the patient the significance of maintaining skin integrity by frequent position changes and keeping the skin clean and dry.

R: To prevent skin and tissue breakdown because of altered sensation and inability to respond to pressure and discomfort

5. Instructed on the importance of compliance to medications R: To increase improvement on patients condition and prevent further complications

Short term: At the end of eight (8) hours, verbalized understanding of condition/prognosis and potential E Long term: At the end three (3) days, the patient initiated necessary lifestyle changes