NCP

Dianne Ingusan

Impaired Social Interaction/Social Isolation

Signs and SymptomsObjective:

IrritablePassive

Sebjective:Verbalized:

“hindi na ata ako gagaling”“sinasayang ko lang panahon ko dito.”“hindi ko kailangan yan, kaya ko na sarili ko”

Nursing Diagnosis

Impaired social interaction or feeling of socially isolated, related to inability to socialize with

people due to Illness (GIST), presence of tumor in the abdominal cavity, that requires complete bed rest with minimal bathroom

privilege.

AnalysisThere was a presence of tumor in her abdominal

cavity that is continuously enlarging creating a stigma, that inhibits her to go out and

socialize with people, which includes fear of rejection from others. Since she is in her

developmental stage of Intimacy V.S. Isolation (Erickson’s Developmental Theory) She has a greater risk of being isolated due to factors

such as hospitalization and acquiring a chronic condition.

Objective

Short term Goal:After an 6 hours of nursing interaction, the patient will be able to verbalize/express her feelings and emotion about her social condition.

Long term Goal:Decrease sense of impaired social interaction/isolation and feeling of helplessness.

InterventionIntervention1.Assess patient’s usual social interaction.

2.Observe for behaviors indicative of social isolation, such as decreased interaction with others, hostility, non compliance, sad affect, and stated feelings of rejection and isolated.

3.Assist patient to identify and explore resources for support and positive mechanism for coping (eg. Contact with family and friends)

Rationale1.Established basis for individualized interaction.

2. Promotes early detection of social isolation, which maybe manifested in several ways.

3.Enables mobilization of resources and support.

EvaluationIntervention4. Allow time to be with patient other that for medications and procedures (therapeutic use of self).5. Encourage participation in diversional activities such as reading, television and hand crafts.

Rationale4. Promotes feelings of self worth and provides social interaction.

5. Provide distraction

Evaluation

Goals were not met, patient was still passive, doesn’t demonstrate interest in events, activities, and

communication, no development of activities/ hobbies that could serves as diversional activities or distraction.

Refuses offers of assistance and support.

Nutrition, Imbalanced: less than body requirement

Signs and SymptomsObjective:

Dry scaly skinProblems in organ functioning (+) splenomegaly,

(+)hepatomegaly (physical assessment)Poor Immune FunctionFatigue and low energyUnderweight manifested (bony structure are prominent)Muscle weaknessDecreased Hemoglobin (72g/L) and hematocrit level ( 0.21 )

Sebjective:Verbalized

“Ang laki nga ng pinayat ko simula nung lumaki itong bukol sa tiyan ko.”

“Nahihirapan ako gumalaw galaw, mabilis ako mapagod.”

Nursing Diagnosis

Imbalanced nutrition, less than body requirement, related to obstruction that

requires modification of diet that conforms to prescribed restrictions yet contains all needed

nutrients.

AnalysisSince there was an obstruction, peristaltic waves becomes extremely

vigorous and eventually assume a reverse reaction, such as: Ileum – fecal vomiting dark fecal like contents

Stomach contents are vomited, no absorption occurs. Bile stained contents Signs of dehydration become

evident (intense thirst, drowsiness, generalized malaise, aching,dec. skin turgor)

This conditions requires the modification of diet to prevent further complication and persistence of such.

ObjectiveShort term Goal:

After an hour of nursing interaction, the patient would be able to understand the importance of balance nutrition.

Long Term Goal:

Improvement of nutritional status, such as returning to normal BMI, improve signs and symptoms of nutritional deficiency such as fatigue, further weight loss, dry and scaly skin, etc.

InterventionIntervention1.Assess for sign and symptoms of malnutrition with ht.wt. age, hemoglobin, hematocrit, 2.Obtain dietary history, including likes and dislikes, allergies and food intolerance.3.Assess factors that interfere with oral intake4.When on NPO, monitor IV Therapy including Caloric Value.5.Gradual instruction of diet from ice chips to clear liquids and introduce soft diet, and solid food as soon as possible.

Rationale1.Provide an objective measure of nutritional assessment.

2.Defines the need for nutritional education; helps individualize nursing intervention.3.Provides basis and direction for intervention.4.Facilitate accurate monitoring

5.This will help the client in slowly improving nutritional status through step by step process.

InterventionIntervention6. Monitor patients response to food intake, increased or decrease symptoms.7. Avoid giving gastric irritants including alcohol, other foods such as spicy food.

Collaborative1. Incorporate Parenteral Nutrition (Kabiven 1400kcal , 1920ml 24 hours @20gtts/min) as ordered.

Rationale6. To evaluate the effectiveness of intervention, if not change or modify approach.7. Gastric irritants will promote further irritation to GI tract that could lead to more complications.

1. Providing nutritional support to an individualwhose gastrointestinal tract is not able to absorb sufficient nutrients or is inaccessible.

KabivenParenteral nutrition is a method of providing nutritional support to an individual whose

gastrointestinal tract is not able to absorb sufficient nutrients or is inaccessible.

PN may be administered either via a central or peripheral vein, the choice being dictated by venous access, the nutritional requirements of the patient and predicted duration on usage. Some of the PN preparations are contraindicated via the peripheral route therefore seek advice from your ward dietitian / pharmacist.

Formulations Within the Trust PN comes as a three chamber all in one bag, where carbohydrate,

nitrogen and fat sources are in separate chambers. These bags have a range of calorie, nitrogen and electrolyte contents and always require additions of vitamins, trace elements and sometimes extra electrolytes.

There are nine ready-made bags available to us from the Kabiven range:

Kabiven 5, 7, 8, 9, 11, 14

Kabiven 8EF, 12EF, 16EF (AllEF are electrolyte free and Structolipid)

Points to Consider (Kabiven)Refeeding Sydrome

Refeeding syndrome is defined as “severe fluid and electrolyte shifts andrelated metabolic implications in malnourished patients undergoing refeeding”.All patients are potentially at risk, whether they are fed via the oral, enteral or

parenteral route; however, the following groups are at high risk;

High risk of developing refeeding problems if one or more of the following

are present: BMI < 16kg/m2 Unintentional weight loss of > 15% in the last 3-6 months Little or no nutritional intake for more than 10 days/5days at least Low levels of potassium, phosphate or magnesium prior to feedinng

For those patients identified at high risk the following should be considered:

Providing immediately before and during the first 10 days of feeding:oral thiamine 200-300mg daily, Vitamin B Co-strong 1-2 tablets 3 timesa day OR full dose daily IV Vitamin B preparation AND a balancedmultivitamin/trace element supplement once daily

At risk patients should have baseline electrolytes, corrected calcium, phosphate and magnesium levels checked and corrected as required and repeated on a daily basis.

Evaluation

No manifestation of improving nutritional status due to enlarging mass, needs further

assessment and modification of treatment.

Fluid and Electrolyte imbalance

Signs and SymptomsObjective:

Na= 126 mEq/L

K=

Lethargy

Subjective:

Verbalized:

“Nararamdaman ko talagang hinang-hina ako.”

Complaints muscle cramps.

Nursing Diagnosis

Fluid and Electrolyte imbalance related to decrease absorption of nutrients and

refeeding syndrome from incorporated parenteral feeding.

Analysis

Due to GIST patient experienced difficulty in nutrient absorption manifested by malnutrition, nausea and vomiting which predisposed her to electrolyte imbalance. She is also a high risk of acquiring Refeeding syndrome(severe fluid and

electrolyte shifts andrelated metabolic implications in malnourished patients

undergoing refeeding) according to the criteria, and this contributed to the manifestation of the

condition.

ObjectiveShort Term Goal:

After 2 to 3 hours of nurse-patient interaction, the patient will be able to understand the importance of achieving a balance fluid and electrolyte level.

Long term Goal:

Clients fluid and electrolyte level will return to normal.

InterventionIntervention1. Institute replacement therapy or restrictions as ordered2. Instruct patient on importance of increasing/decreasing fluid intakein relation to illness.3. Monitor I & O accurately.

4. Monitor daily weight.

Collaborative: 1.Administer Calsium Bicarbionate (500mg/tab TID) as ordered.2.Administer Kalium durule ()1durule (1doseTID) as ordered.

Rationale1. To monitor closely and control further complication.2. The patient is vulnerable to fluid overload / retention.

3. Monitor for abnormalities/or complication.4. Monitor abnormal increase of weight due to fluid retention.

Ca= 1.4Meq/L

K= 3.3.Meq/L

Kalium Durule GENERIC NAME: Potassium chloride, potassium gluconate

BRAND NAME: Apo-K, K-10, Kalium Durules, Kaochlor, Kaon-Cl, Kato, Kay Ciel, KCl 5% and 20%, Klor-Con, Klorvess,

K-lyte/Cl, K-tab, Rum-K, Kaylixir,

CLASSIFICATION: electrolytic and water balance agent, replacement solutions

THERAPEUTIC EFFECTS: given special importance as therapeutic agents, but may be dangerous if improperly Rx and admin

Utilized for Tx of hypokalemia USES: prevent and treat potassium deficit secondary to diuretic or corticosteroid

therapy.When K+ is depleted by severe Vomiting, diarrhea; intestinal drainage, fistulas or malabsorption, prolonged diuresis, diabetic acidosis. Effective inT x of hypokalemicalkalosis.

SIDE EFFECTS: N/V, ECG changes in hyperkalemia

Kalium Durule • Nursing Implications & teaching.

– Tablet carcass may appear in stool, do not be alarmed.Sustained release tablet utilized a wax matix as carrier for KCl

– crystals that passes through the digestive system– Learn about sources of K+ with special reference to foods and OTC drugs– Avoid licorice, large amounts cause both hypokalemia and Na+ retention– Do not use salt substitute unless specifically ordered by Dr.these contain

substantial amount of K+, and electrolytes– other than Na+– Do not self prescribe laxatives.Chronic laxative use has been associated with

diarrhea-induced K+ loss– Notify Dr of persistent vomiting because losses of K+ can occur– Report weakness, fatigue, polyuria, polydipsia: could be signs of K+ deficit– Advice dentist or new Dr that K+ has been prescribed as long-term maintenance

program– Do not open foil-wrapped powders and tablets before use

Calcium Carbonate CALCIUM CARBONATE; RISEDRONATE (Actonel® with Calcium) is a

combination of medicines used to reduce calcium loss from bones. It helps prevent bone loss and increases production of normal healthy bone in people with postmenopausal osteoporosis. Generic Actonel® with calcium tablets are not yet available.

Side effects that you should report to your prescriber or health care professional as soon as possible:• black or tarry stools• changes in mental status• constant jaw pain, especially burning or cramping• drowsiness or dizziness• eye inflammation, pain, or vision change• loss of appetite• low levels of calcium in the blood (may cause symptoms like confusion, severe fatigue, or weakness)• pain or difficulty when swallowing• skin rash, itching• stomach pain• swelling of the lips, face, tongue, or throat• weakness

Calcium Carbonate Classification

– mineral and electrolyte

– replacements/supplement

Mechanism of action and indications– Mineral/electrolyte/vitamin supplement

Nursing Implication Hypercalcemia Renal Caleculi Ventricular Fibrillation

Nursing Teachings Instruct patient not to take enteric-coated tablets within 1 hr of

calcium carbonate; this will result in premature dissolution ofthe tablets.

Do not administer concurrently with foodscontaining large amounts of oxalic acid (spinach, rhubarb),phytic acid (brans, cereals), or phosphorus (milk or dairyproducts).

Administration with milk products may lead tomilk-alkali syndrome (nausea, vomiting, confusion,headache).

Do not take within 1-2 hr of other medications ifpossible.Instruct patients on a regular schedule to takemissed doses as soon as possible, then go back to regularschedule.

Advise patient that calcium carbonate may causeconstipation. Review methods of preventing constipation(increasing bulk in diet, increasing fluid intake, increasingmobility) and using laxatives.

Severe constipation mayindicate toxicity.

Advise patient to avoid excessive use oftobacco or beverages containing alcohol or caffeine

Evaluation

There was no updated blood test done. Short term goals were met, patient was able to

understand the importance of balanced fluid and electrolyte levels in the body.