XIII.

Nursing Care Plan

ASSESSMENT

DIAGNOSIS

RATIONALE

PLANNING

NURSING INTERVENTION Assess vital signs.

RATIONALE

EVALUATION

*SUBJECTIVE: Kumikirot ang leeg ko lalo na pag akoy napapagod. As verbalized by the patient.

Fatigue related to hypermetabolic imbalance with increased energy requirements, irritability of CNS, and altered body chemistry, as evidenced by

An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.

After 30-35 minutes of nursing intervention the patient will: Identify basis of fatigue and individual areas of controlled. Report improved sense of energy. Participate in

To evaluate fluid status and cardiopul monary response to activity. Fatigue can be a

After 30-35 minutes of nursing intervention the patient has been: Identified basis of fatigue and individual areas of controlled. Reported improved sense of energy. Participate d in

*OBJECTIVE: Restlessness Pallor Drowsy Decreased performance Emotional

verbalization of overwhelming lack of energy to maintain usual routine, decreased performance, emotional lability/irritability, REFERENCE:

Determine presence/deg ree of sleep disturbance.

consequen ce of, and/or exacerbate d by, sleep deprivatio

recommende

irritability Pain scale of 6 Vital signs taken:

and impaired ability to concentrate.

Nurses Pocket Guide by: Doenges, Moorhouse, Murr. Page 307.

d treatment program.

n. Helpful in determinin Note daily energy g patterns/ti ming of activity. That indicates Instruct client in ways to monitor responses to activity and significant signs/sympto ms. Promotes Assist client sense of the need to alter activity level.

recommend ed treatment program.

BP: 130/80 TEMP: 36C RR: 20 bpm PR: 68 bpm

patterns.

to identify appropriate coping behaviors.

control and improve selfesteem.

REFERENCE: Nurses Pocket Guide by: Doenges, Moorhouse, Murr. Page 307312.

ASSESSMENT

DIAGNOSIS

RATIONALE

PLANNING

NURSING INTERVENTION

RATIONALE

EVALUATION

After 20-30 *SUBJECTIVE: Hindi ako gaanong makatulog dahil kinakabahan ako sa kung anong pwedeng mangyari sa akin sa operation. As verbalized by the patient. Anxiety related to increased stimulation of the CNS (hypermetabolic state, pseudocatecholam ine effect of thyroid hormones), possibly evidenced *OBJECTIVE: Irritability Inability to concentrate Fine hand by increased feelings of apprehension overexcitement/dis tress, irritability/emotion Prolonged periods of time without sleep (sustained natural, periodic suspension of relative consciousness). Identify individuall y appropriate interventio ns to promote sleep. Verbalize understandi ng of sleep disorder. Instruct in relaxation techniques, To decrease tension, Investigate anxious feelings. To help determine basis and appropriate anxietyreduction technique. After 20-30 minutes of nursing intervention the patient will: Determine interventions client has tried in the past. Identified individuall y appropriat e interventio ns to promote sleep. Verbalize d understan Helps identify appropriate options. minutes of nursing intervention the patient has been:

tremors Agitation

al lability, shakiness, restless REFERENCE: Nurses Pocket Guide by: Doenges, Moorhouse, Murr. Page 630.

Report improveme nt in sleep/rest pattern

music therapy, meditation, etc.

prepare for rest/sleep.

ding of sleep disorder. Reported

Vital signs taken: movements, tremors. BP: 130/80 TEMP: 36C RR: 20 bpm PR: 68 bpm

To reduce Limit evening fluid intake if nocturia is present. To help Encourage family counseling. deal with concerns arising from parasomnia s. stimulation so client can relax.

improvem ent in sleep/rest pattern

REFERENCE: Nurses Pocket

Guide by: Doenges, Moorhouse, Murr. Page 630-634.

ASSESSMENT

DIAGNOSIS

RATIONALE

PLANNING

NURSING INTERVENTION Accept clients description of pain. Acknowled

RATIONALE

EVALUATION

*SUBJECTIVE: Kumikirot ang leeg ko lalo na pag akoy napapagod. As verbalized by the patient.

Acute pain related to presence of preoperative edema, as evidenced by verbal reports, guarding

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and duration of

After 35-45 minutes of nursing intervention the patient will: Report pain is relieved/cont rolled. Follow prescribed pharmacolog ical regimen. Verbalize nonpharmacolog ic methods that provide

Pain is a subjective experience and cannot be felt by others.

After 35-45 minutes of nursing intervention the patient has been: Reported pain is relieved/cont rolled. Followed prescribed pharmacolog

ge the pain experience and convey acceptance of clients response to pain. Which are Monitor skin color/tempe rature and vital signs. usually altered in acute pain.

*OBJECTIVE: Guarding behaviors Protective gestures Positioning to avoid pain. Sleep disturbance

behaviors, narrowed focus, and autonomic responses (changes in vital signs).

ical regimen. Verbalized nonpharmacolog ic methods that provide

 Restlessness Irritability Pain scale of 6. Vital signs taken:

less than 6 months.

relief. Demonstrate use of relaxation skills and diversional activities, as Note when pain occurs (e.g., only with ambulation, every evening).

To medicate prophylacticall y, as appropriate.

relief. Demonstrate d use of relaxation skills and diversional activities, as indicated, for

BP: 130/80 TEMP: 36C RR: 20 bpm PR: 68 bpm

REFERENCE: Nurses Pocket Guide by: Doenges, Moorhouse, Murr. Page 498.

indicated, for individual situations.

To promote Provide comfort measures, quiet environment , and calm activities. Administer analgesics, as indicated, to maximum dosage, as To maintain acceptable level of pain. Notify physician if nonpharmacologic al pain management.

individual situations.

needed.

regimen is inadequate to meet pain

Encourage adequate rest periods. Provide for individualizi ng physical therapy/exer cise program that can be continued by the client after discharge.

control goal. To prevent fatigue. Promotes active, not passive, role and enhances sense of control.

REFERENCE: Nurses Pocket Guide by: Doenges, Moorhouse, Murr. Page 498-503.