NURSING CARE PLAN Assessment Subjective: Hindi ako makaihi kahit anung pilit ko, as verbalized by the client.

. Diagnosis Urinary retention related to reduced bladder muscles contractility Scientific knowledge Planning Short term goal: administration of anicholinergic drug (atrophine sulfate) - Within 2-3 hours of nursing intervention the client will: verbalize understanding causative factors and appropriate interventions. Intervention INDEPENDENT: Assist to upright position on bedpan Provide privacy Use ice techniques, spirits of wintergreen, stroking inner thigh, running water or warm water over perineum. DEPENDENT: Catheterize with intermittent or indwelling catheter To provide functional position of voiding. Stimulate reflex arc Resolve acute urinary retention Goal met -after 2-3 hours of nursing intervention the client: verbalized understanding causative factors and appropriate interventions. demonstrate techniques and behavior to alleviate retention Goalmet - after 2 days of nursing intervention Rationale Evaluation

Objective: Post-operative Urine-output= 0 With palpable bladder distention

stimulation of SNS

inhibition of acetyl choline production

Reference: Nurses pocket guide, pp. 754

demonstrate techniques and behavior to alleviate retention

decreased bladder contractility

Long-term goal: -Within 2 days of nursing intervention

signs and symptoms (urinary retention)

the client will void in sufficient amounts with no palpable bladder distention.

the client voided in sufficient amounts with no palpable bladder distention

(Medical-Surgical Nursing 10th edition - Brunner & Suddarth)

ASSESSMENT Subjective: nahihirapan ako kumilos dahil sa aking tahi as verbalized b the client.

DIAGNOSIS

Scientific knowledge Surgical incision of the abdominal wall

PLANNING

INTERVENTION

RATIONALE

EVALUATION Goal met

Objective:

Activity intolerance related to surgery as manifested by decreased mobility.

Short term goal: -within 5-8 hours of nursing intervention the client will:

Adjust activities Increase exercise levels gradually. Plan care to carefully balance rest periods with activities. Provide positive atmosphere Promote comfort measures Encourage client to maintain positive attitude.

Actual tissue damage

Tired facial expression Uncomfortable Worried In pain (7/10 pain scale) T- 36.4 C P- 84 bpm R-22breaths/min

peripheral receptors initiate unpleasant sensations

use identified techniques to enhance activity tolerance Willingly participate in necessary/ desired activities. Report measurable increase n activity tolerance. Demonstrate a decrease in physiological signs of intolerance. Long-term goal: -within 2 days of nursing intervention the client will tolerate her activities.

To prevent overexertion. Nurses pocket guide 11th edition, pp. 72 To conserve energy. Nurses pocket guide 11th edition, pp. 72 To reduce fatigue Nurses pocket guide 11th edition, pp. 72 Helps minimize frustration and rechannel energy Nurses pocket guide 11th edition, pp. 72 To enhance sense of wellbeing

-after 5-8 hours of nursing intervention the client: used identified techniques that enhance activity tolerance Participated willingly in desired activities. Reported measurable increased in activity tolerance. Demonstrated decreased in physiological signs of intolerance. Goal met After 2 days of nursing intervention, the client can tolerate her activities

modulation in the dorsal horn of the spinal cord

activation in the cerebral cortex

pain sensation

Assessment

Diagnosis

Scientific knowledge

Planning

Intervention

Rationale

Evaluation

Subjective: ang sakit ng tahi ko, as verbalized by the client.

Acute pain related to actual tissue damage as manifested by Pain scale of 7 over 10.

Short term goal: Surgical incision of the abdominal wall Within 23hour of nursing intervention the client will: verbalize method that provide relief demonstrate relaxation skills and divertional activities as indicated for her situation follow prescribe pharmacolog ical regimen.

INDEPENDENT: Instruct client to report any improvement/aggr avation in pain experience Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client. Very few people lie about pain. (Medical-Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 443) To promote nonpharmacological pain management (nurses pocket guide, 11thed. By Doenges Marilynn, p.501 Deep breathing for relaxation is easy to learn and contributes to pain relief and/or reduction by reducing muscle tension and anxiety (Medical-Surgical, 7thed. By black, joyce M. &janeHokansan hawks; p.479) Goalmet After 2-3hour of nursing intervention the client: verbalized method that provide relief (the patient stated methods that provide relief like changing position)

Objective: Facial grimace Guarding behavior Irritability Withdrawn behavior T- 36.4 C P- 84 bpm R-22breaths/min

Actual tissue damage

peripheral receptors initiate unpleasant sensations

Provide comfort measures(back rub, change of position)

modulation in the dorsal horn of the spinal cord

Long-term goal: -Within 8 hours of nursing intervention the client will report pain is relieved or

Encourage and assist client to do deep breathing exercises.

activation in the cerebral cortex

demonstrated relaxation skills and divertional activities as indicated for her situation (the client can demonstrate deep breathing exercise)

controlled.

pain sensation ( acute pain)

To maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal. (nurses pocket guide, 11th ed. By Doenges Marilynn, p.502) Followed prescribe pharmacologic al regimen. (the patient is able to take analgesic in right time without refusal.)

(Medical-Surgical Nursing 10th edition - Brunner & Suddarth)

Reference: Nurses pocket guide, pp. 754

DEPENDENT:

Administer analgesic as indicated to maximal dosage as needed.

ASSESSMENT

DIAGNOSIS

SCIENTIFIC KNOWLEDGE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Impaired tissue integrity related Objective: to surgical Incision at RUQ incision T-tube drain with slightly soaked.

Surgical incision of the abdominal wall

Short term goal:

removal of the bile bladder

-within 4-5 hours of nursing intervention, the client will be able to: Demonstrates understanding of plan to heal skin Describes measures to protect and heal the skin and to care for any skin lesion Long-term goal:

Check the T-tube drain; make sure that they are free flowing.

Incision site drains are used to remove any accumulated fluid and bile. Correct positioning prevents back up of the bile in the operative area. Initially, may contain blood and bloodstained fluid, normally changing to greenish brown (bile color) after the first several hours. Facilitates drainage of

Goal Met After 4-5 hours of nursing intervention, the client :

Observe color and character of the drainage.

application of T-tube

Demonstrates understanding of plan to heal skin Describes measures to protect and heal the skin and to care for any skin lesion

Impaired skin integrity

Place patient in low or semi-fowlers position. bile.

Within 3 weeks of nursing intervention the client will regains integrity of skin surface.

change dressings as often as necessary.

Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation.

-Necessary for treatment or prophylaxis for