NURSING CARE PLAN

Name: Mr. R.M. Age: 55yrs old Diagnosis: Distal Esophageal Mass s/p Biopsy (Lymphoma) ASSESSMENT NURSING DIAGNOSIS Acute pain related to disease process as evidenced by increased systolic pressure, abdominal guarding and report of 5/10 abdominal pain. PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Tulong aldaw na akong dae nakakabawas saka makulog pag tigakaputan digdi sa may parteng tulak ko. as verbalized by patient. OBJECTIVE: -BP= 140/80mmHg -needs assistance upon getting up on bed -refused to ambulate or to do ROM exercises - slowed movement -unable to pass stool -distended abdomen -abdominal tenderness noted -conscious and coversant

After 4 hours of nursing intervention the client will verbalize pain relief and comfort.

Independent: Perform a comprehensive Pain is a subjective assessment of pain to experience and must be include location, described by the client in characteristics, onset, order to plan effective duration, frequency, treatment. quality, intensity or severity, and precipitating factors of pain. Reduce or eliminate Personal factors can factors that precipitate or influence pain and pain increase patients pain tolerance. Factors that may experience. be precipitating or augmenting pain should be reduced or eliminated to enhance the overall pain management program. Teach the use of non The use of noninvasive pain pharmacologic techniques relief measures can increase before, after, and if the release the release of possible during painful endorphins and enhance the activities; before pain therapeutic effects of pain occurs or increases; and medications. along with other pain relief measures.

After 3 hours of nursing intervention, the client verbalized pain relief and comfort.

Dependent Provide client optimal Each client has a right to pain relief with prescribed expect maximum pain relief. analgesics. Instruct patient to request Severe pain is more difficult prn pain medication to control and increases the before the pain is severe. clients anxiety and fatigue. The preventive approach to pain management can reduce the total 24-hour analgesic dose.

Constipation related to insufficient physical activity

After 2 days of nursing intervention, the patient will be able to establish/regain normal pattern of bowel movement, demonstrate behaviors or lifestyle changes to prevent recurrence of problem, and participate in bowel program as indicated.

Independent Auscultate abdomen for presence, location, and characteristics of bowel sounds. Ascertain clients belief and practices about bowel elimination. Ascertain clients usual elimination pattern. Encourage intake of balanced fiber and bulk in diet. Promote increased fluid intake unless contraindicated. Encourage participation in activity/exercise within limits of own ability. Instruct patient to respond to urge to

Reflects bowel activity

To identify individual risk factors/needs. To assess individual risk factors/needs. To improve consistency of stool and facilitates passage through colon. To promote moist/soft stool. To stimulate contractions of intestines. To promote comfort and prevent complications.

After 2 days of nursing intervention, the patient was able to establish/regain normal pattern of bowel movement, demonstrate behaviors or lifestyle changes to prevent recurrence of problem, and participate in bowel program as indicated.

defecate. Instruct client and watcher to ascertain frequency, color, consistency of stool once defecated. Collaborative: Notify physician for unusalities.

To help monitor bowel pattern.

For prompt management.

Dianne Kaye M. Sarmiento

BUCN BSN III-C Group 12