nursing care plan er
TRANSCRIPT
8/3/2019 Nursing Care Plan ER
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By: Ma. Theresa Medrocillo St.N
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Date Cues Need NursingDiagnosis
Objectives Interventions Evaluation
AU
GUST
15,
2011
@
7am
O:
PainScale = 3severepain
Facial
Grimacenoted
Guardingbehaviour noted
C
O
G
N
I
T
I
VE
-
Acute Painrelated to
EnlargedLiver andAbdominaldistention
After my 3days span
of care mypatient willbe able toexperiencealleviationof pain as
manifestedby:
1. Reassesslocation
andcharacterof painwhen theclientreports
discomfort.
® Assessmentprovidesinformationabout thecause of pain.
August17, 2011
“ Goal
PartiallyMet”
At the endof my 3days spanof caremypatientwaspartially
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Objectives Interventions Evaluation
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15,
2011
@
7am
Ascitesnoted
Abdominaldistention noted
Dx:
CT scanand USDshowshepatomegalyandascites
PE
RCEPTU
AL
PAT
TERN
Rationale: In livercirrhosis, abdominalpain may be present
because of recent,rapid enlargement ofthe liver, producingtension on thefibrous covering ofthe liver (Glisson’s capsule). Later inthe disease the liverdecreases in size as
scar tissue contractsthe liver tissue. Theliver edge ispalpable, is nodular.Abdominaldistention, causedby ascites, cancause compressionof surrounding
organs and over-expansion of thesurrounding skincausing stimulationof pain receptors.(Med-Surg Nursingby Bare, pp. 1102)
A.Verbalizatio
n of relieffrom painusing thepain scalelevel of 0 to1 as:
0 – no pain1 – mild pain2-
moderatepain3- severepain
2. Reassesspatient’s
perception ofpain intensityusing a scale of1 to 5 with 1being the leastand 5 being themost pain.
® Assessmentprovidesquantitativeinformationabout patient’s
perception ofpain and guidesthe choice ofmedications.Level of pain iswhat the clientsays it is
experienced
alleviationof pain asmanifested by:
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2011
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B.maintenanc
e of hernormal vitalsigns of:
PR: 60- 100bpm
CR: 60 – 100 bpm
RR: 16 -20cycle
Temp: 36.1-37.2BP:110/70 – 130/90mmHg
3. Observenonverbal cues
and painbehaviors suchas how patientsleeps, sits,holds body, andfacialexpressions.
® Observationsmay or may notbe congruentwith verbal cuesindicating the
need for furtherevaluation.
a. verbalization
ofreliefof painbutpainstill
returns – intermittentpain
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c. beingrelaxed; not
restless andsighing;
4. Monitor thepatient’s vital
signs.
® Vital signsare altered inacute pain.
5. Administerappropriatemedication asordered.
® To relievepain
b.maintena
nce ofnormalvital signsof:Temp.:36.3 ºC
BP:110/80mmHgCR: 98bpmRR: 20cpm
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2011
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c. beingrelaxed; not
restless andsighing;
4. Monitor thepatient’s vital
signs.
® Vital signsare altered inacute pain.
5. Administerappropriatemedication asordered.
® To relievepain
c.However,
thepatientfeelsrestlessdue to thepain and
pressurefelt due toabdominaldistention.
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2011
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c. beingrelaxed; not
restless andsighing;
4. Monitor thepatient’s vital
signs.
® Vital signsare altered inacute pain.
5. Administerappropriatemedication asordered.
® To relieve
pain
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2011
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6. Note thelocation of the
surgicalprocedure.
® This caninfluence theamount of
post operativepainexperienced.Example,vertical/diagonal incisions
are morepainful thantransverse orS-shapedones.
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2011
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7) Assesspatency of
drains andcatheters.
® Obstructedflow of urinewill result in
increasedrenal pressureandcause/intensify pain.
8. Changedressing asindicated.
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2011
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® To preventinfection
which maycause addedpain.
9) Encourageto have
enough bedrest and restperiods.
® To preventfatigue.
10) Reassesspatient forpain relief.Observe forside effects.
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® Assessmentprovidesinformationaboutpatient’s
response tomedication.
Assist patientto changeposition, assoon aspossible.
Providecomfortableenvironment.
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2011
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® Assessmentprovides
informationaboutpatient’s
response tomedication.
11.) Assistpatient tochangeposition, assoon aspossible.
Providecomfortableenvironment.
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2011
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® Positionchanges
decreasesmuscletension,comfortableenvironmentenhances
relaxation.
12.) Teachpatient to askfor painmedication
before painbecomessevere.
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® Painmedication is
more effectiveand less isneeded ifgiven beforepain is severe.
13.)Encourageand assistpatient to dodeepbreathing
exercises.
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2011
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Deepbreathing for
relaxation iseasy to learnandcontributes topain reliefand/or
reduction byreducingmuscletension andanxiety.
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2011
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14. Offernonpharmacol
ogicalinterventions ifdesired suchas therapeutictouch, backrub, music.
® Nonpharmacologicalinterventionsmay use
distraction todecrease painperception.
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2011
@
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15. Provide
psychologicalsupport/motivation.
® To ascertainthe motivation
for returningto an optimallevel ofwellness.
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2011
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16.) Notify
watcher orphysician ifpain is notcontrolled or ifcomplicationsare suspected
® Watchermay order adifferentanalgesic ordecide to re-
evaluate thepatient.