ncp gouty arthritis

V. NURSING MANAGEMENT

PRE-OPERATIVE NURSING CARE PLANS

Problem # 1: Acute Pain

AssessmentNursing

DiagnosisScientific

explanationObjectives

Nursing Interventions

RationaleExpected Outcome

S= ᴓ

O=Patient manifested:

Limited movements

Body malaise Guarding

behavior facial

grimaces crying irritability increased

vital signs especially BP

Acute pain related to bowel distension secondary to disease condition

The presence of a tumor creates an obstruction in the colon and because of this mechanical obstruction or fecal impaction, there is an impairment of flow in the intestinal contents of the GI. This would activate the secretory cell activity, releasing fluid and air which would then collect to the proximal

Short term:After 4 hours of nursing interventions, the patient’s pain will be minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10.

Long Term:After 3 days of nursing interventions, the patient will be relieved from pain

Establish rapport

Assess the patient’s condition

Assess vital signs.

Assess patient’s degree of pain every time she verbalizes pain

To gain patient’s trust

To obtain baseline data and to plan for the appropriate care

Alteration in Vital signs is evident in the presence of pain

To obtain information about the pain that the patient is manifesting

Short term:The pain shall have been minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10.

Long Term:The patient shall have been relieved from pain and will have vital signs within normal limits.

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P- movement

Q- sharp

R- mid abdomen

S- pain scale of 6/10

T-every time movement is elicited

patient may manifest:

perspiration signs and

symptoms of inflammation at surgical site

moaning, shouting, sighing

site of the obstruction. As a result, fluid and air accumulation occurs and thus distension occurs. This distension would then cause pressure and irritation of the nerve endings within the intestinal mucosa

and will have vital signs within normal limits.

Reposition patient

Provide quiet environment

Provide comfort measures

Advise the patient to deep breathing exercises.

Encourage patient to do diversional activities such as watching TV or talking to a family members

Administer analgesics as prescribed

Serves as a comfort measure

To decrease environment stimulus and promote rest

To alleviate feeling of pain

To lessen pain

To lessen pain by allowing the patient to focus on other things

Provides pharmacologic treatment to lessen patients pain

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Problem # 2: Mild Anxiety

AssessmentNursing

DiagnosisScientific




S= ᴓ


Restlessness Irritability Increased

perspiration Anorexia Insomnia


perspiration

signs and symptoms of inflammation at surgical site

Anxiety related to threat of death and possible complications after surgery

Fear of the unknown is the most prevalent causes of preoperative anxiety. The patient experienced a vagua uneasy feeling of discomfort or dread accompanied by an autonomic response. A feeling of apprehension caused by anticipation of danger in surgery.

It enables the client to take measures to deal with the threat.

Short term:After 4 hours of nursing interventions, the patient’s pain will use resources and support system effectively.

Long Term:After 4 days of nursing interventions, the patient will appear relaxed and report anxiety is reduced to a manageable level.

Assess patient’s general condition

Monitor and record vital signs

Observe the patient’s behaviour indicative of level of anxiety.

Identify the patient’s coping skills and review coping skills in the past.

Establish a

To know the patient’s condition and provide necessary actions and interventions.

To obtain baseline data

This can be a clue to the patient’s anxiety level

To determine those that might be helpful in current circumstances

To assist patient

Short term:The patient’s pain shall have used resources and support system effectively.

Long Term:The patient shall have appeared relaxed and reported anxiety is reduced to a manageable level.

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therapeutic relationship, conveying empathy and unconditional positive regard.

Acknowledge anxiety or fear.

Provide accurate information about the situation

Provide comfort measures such as providing calm/quiet environment, soft music and back rub.

to identify feelings and begin to deal with problems.

Do not deny or reassure patient that everything will be alright

Helps patient to identify what is reality based

To limit degree of stress. Helpful in reducing level of anxiety by relieving tension

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Problem # 3: Risk for Fluid Volume Deficit

AssessmentNursing

DiagnosisScientific




S- ᴓ

O- patient manifested:

VomitingAbdominal

distension

Patient may manifest:

DehydrationHypotensionHypovolemic

shock

Risk for fluid volume deficit related to vomiting decreased intestinal reabsorption of fluid and decreased intestinal secretions secondary to disease condition

Normally, the bowel secretes 7-8 L of electrolyte-rich fluid, and most of the fluid is absorbed. When the bowel is obstructed by a tumor, this fluid is partially retained within the bowel and partially eliminated by vomiting causing severe reduction in circulating blood volume which may result in hypotension, hypovolemic shock and diminished real and cerebral blood flow.

Short term:After 5 hours of nursing interventions, patient will be relieved from vomiting.

Long term:After 3 days of NPI the patient will maintain volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, moist mucous membranes, good skin turgor, and prompt capillary refill.

Assessed patients overall status

Monitor and record vital signs

Monitor intake and output

Auscultate bowel sounds

Observe for signs of dehydration

To obtained baseline data for future references


To ensure accurate picture of fluid status.

To assess the quality of bowel sounds. A lack of bowel sounds indicates peritoneal irritation

To make necessary interventions.

Short term:The patient shall have been relieved from vomiting.

Long term:The patient shall have been maintained a volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, moist mucous membranes, good skin turgor, and prompt capillary refill.

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Establish individual needs/replacement schedule

Provide supplemental fluids as indicated

Provide small frequent feedings

Administer anti-emetic medications as ordered.

To correct the deficit

To prevent peaks and valleys in fluid level

To maintain the nutritional needs of the patient

To reduce patient’s vomiting episodes.

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INTRA OPERATIVE NURSING CARE PLANS

Problem # 1: Risk for Infection

AssessmentNursing

DiagnosisScientific




S= ᴓ

O=patient may manifest:


increase in vital sign

signs and symptoms of shock

Risk for infection

Surgery is performed using aseptic technique and in a manner to prevent cross contamination. During the operation, a surgical incision must be made. Breaks in the integument, the body’s first line of defense, and/or the mucous membranes allow invasion by pathogens. If the patient’s immune system cannot combat the invading organism adequately, an infection occurs. Open wounds, traumatic or surgical, can be sites for infection during and after an invasive

Short term:After 4 hours of nursing interventions, the patient’s surgery is performed using aseptic technique and in a manner to prevent cross contamination.

Long Term:After 5 hours of nursing interventions, the patient will be free of signs and symptoms of infection.

Implements aseptic technique.

Classifies surgical wound.

Assesses susceptibility for infection.

Performs skin preparations.

Monitors for signs and symptoms of infection.

To maintain a sterile field during the operation

To know to the preventive measures to be taken

To be able to administer prophylactic treatment

Ensures that lessening of risk for infection

To enable proper and early management of signs and symptoms

Short term:The patient’s surgery shall have been performed using aseptic technique and in a manner to prevent cross contamination.

Long Term:The patient shall have been free of signs and symptoms of infection.

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procedure. Minimizes the

length of invasive procedure planning care.

Administers prescribed prophylactic treatments.

Administers care to wound sites.

To lessen occurrence or possibility of trauma and infection

To provide pharmacological management for infection

To minimize exposure of wounds to microorganisms

Problem # 2: Risk for Impaired Skin Integrity Related to Positioning, Immobilization, Pressure or Shearing Forces

78

AssessmentNursing

DiagnosisScientific




S= ᴓ



increase in vital sign

Pressure sores

Redness or blemishes

Risk for impaired skinintegrity related topositioning, immobilization,pressure,and/or shearing forces

Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; potentiate the effects of pressure and hasten the development of skin breakdown. Improper positioning and surgical management during the operation can predispose the occurrence of

Short term:After 4 hours of nursing interventions, the patient’s skin remains smooth, intact, non-reddened, non-irritated, and free of bruising, other than surgical incision.

Long Term:After 5 hours of nursing interventions, the patient will be free of signs and symptoms of physical injury.

Identifies physical alterations that may affect procedure- specific positioning.

Positions the patient.

Implements protective measures to prevent skin or tissue injury due to thermal, chemical, or mechanical sources.

Evaluates for

To determine extent of adjustment when performing positioning

To ensure that the patient is comfortable and position is appropriate for the procedure

To avoid trauma from external forces in the environment

To observe

Short term:The patient’s skin shall have remained smooth, intact, non-reddened, non-irritated, and free of bruising, other than surgical incision.

Long Term:The patient shall have been free of signs and symptoms of physical injury.

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disruption of skin integrity thus management must be done to minimize such.

signs and symptoms of injury to skin and tissue.

Evaluates for signs and symptoms of injury as a result of positioning.

for any alterations in skin integrity

To provide prompt management of identified signs and symptoms

Problem #3: Risk for Hypothermia

AssessmentNursing

DiagnosisScientific




S= ᴓ


Chills

Risk for hypothermia

Hypothermia occurs when the body’s core temperature falls below its normal level of 98.6°F to

Short term:After 4 hours of nursing interventions, the patient’s core body

Implements thermoregulation measures.

Monitors body

To prevent a decrease in body temperature

To monitor

Short term:The patient’s core body temperature shall have remained within

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Cold clammy skin

Decrease in vital signs

Cyanotic nail beds

Tremors Hypotension Rapid and

weak pulse

95°F or colder. It is the opposite of fever, when the body’s temperature is above normal. The operating room must be kept in a certain temperature to reduce the growth of microorganisms and prevent the build up of moisture. With that, the room is maintained in a cool temperature. This in turn predisposes the patient in to experiencing hypothermia because of his/her environment. Hypothermia is dangerous because it affects the

temperature will remain within expected range.

Long Term:After 5 hours of nursing interventions, the patient will be at or return tonormothermia at the conclusionof the immediate postoperative period.

temperature.

Evaluates response to thermoregulation.

Perform insulation measures like warming blankets, socks, head covering and other apparel

Warming of IV fluids as ordered

patients core temperature

To perform appropriate measures and management

Increases in ambient temperature are used to keep the peripheral tissue closer to target temperatures

Significantly reduces the impact of vasodilation and redistribution hypothermia

expected range.

Long Term:The patient shall have been at or returned to normothermia at the conclusionof the immediate postoperative period.

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body's core – the brain, heart, lungs, and other vital organs. accidents. Severe hypothermia causes loss of consciousness and may result in death.

POST OPERATIVE NURSING CARE PLANS

Problem # 1: Acute Pain R/T Disrupted Skin Integrity, Damaged Tissues and Nerves

AssessmentNursing

DiagnosisScientific




S= “kumikirot ung tahi ko sa

Acute pain r/t disrupted skin

Pain is an expected

Short term:After 4 hours of

Establish rapport

To gain Short term:The pain shall

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tiyan”. as verbalized by the pt.


facial grimaces

crying irritability increased

vital signs especially BP

P- movementQ- sharp

R- mid abdomen S- pain scale of 6/10

T-every time movement is elicited


perspiration

integrity, damaged tissues and nerves

outcome post-operatively. And because pain is intensified with movement increase in discomfort is exhibited. Due to the presence of a surgical incision, continuity in the integrity of the skin is interrupted. The abundance of nerve endings in the skin makes it very sensitive to pain stimuli. Trauma such as cuts and incisions in invasive procedures post operatively, the release of nociceptors that transmit pain stimuli and there is the release of chemicals such

nursing interventions, the patient’s pain will be minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10.

Long Term:After 3 days of nursing interventions, the patient will be relieved from pain and will have vital signs within normal limits.

Assess the patient’s condition

Assess vital signs.

Assess patient’s degree of pain every time she verbalizes pain

Reposition patient

Provide quiet environment

Provide comfort measures

Advise the

patient’s trust

To obtain baseline data and to plan for the appropriate care

Alteration in Vital signs is evident in the presence of pain

To obtain information about the pain that the patient is manifesting

Serves as a comfort measure

To decrease environment stimulus and promote rest

To alleviate feeling of pain

have been minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10.

Long Term:The patient shall have been relieved from pain and will have vital signs within normal limits.

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as histamine, bradykinin and prostaglandin that contributes to the experience of pain.

patient to deep breathing exercises.

Encourage patient to do diversional activities such as watching TV or talking to a family members

Administer analgesics as prescribed

To lessen pain

To lessen pain by allowing the patient to focus on other things

Provides pharmacologic treatment to lessen patients pain

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Problem # 2: Risk for Spread of Infection r/t Inadequate Primary Defenses (Broken Skin, Traumatized Tissue)

AssessmentNursing

Diagnosis

Scientific

ExplanationPlanning Intervention Rationale

Expected

Outcome

S= ᴓ

O= Pt. may manifest:

with wound dressing

May manifest:

drainage in the surgical site.

Increased WBC count

Risk for spread of infection r/t inadequate primary defenses (broken skin, traumatized tissue)

There are normal flora residing in our skin and these microorganisms are opportunistic in nature. As a result of the disruption in the skin integrity, these microorganisms may cause an increased risk to infection due to the break in the continuity of the skin, the body’s first line of defense. This disruption serves as a portal of entry for

Short Term:After 4 hours of nursing interventions, the client will be free from infection.

Long Term:After 3 days of nursing interventions, the patient shall get rid or there shall be a total elimination of risk for infection.

Observe aseptic techniques when handling the patient.

Instruct patient to avoid touching wound with bare hands.

Provide sterile dressing

To prevent the spread of microorganisms, proper washing is a first line of defense against nosocomial infection.

It may predispose the occurrence of infection since the hands are also carrier of microorganisms.

Prevent environmental contamination

Short Term:The risk for infection shall have been minimized

Long Term:The patient shall have no infection AEB WBC within normal range

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soiled dressing

redness of affected area

presence of pus at the surgical incision

swelling of affected area

skin is warm to touch at the affected area

microorganisms.

Encourage patient to increase fluid intake

Administer antibiotics as ordered

of fresh wounds

To prevent possible recurrence of infection

To provide pharmacological treatment

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Problem # 3: Risk for Aspiration Related to Impaired Swallowing Due to Previous Placement of Nasogastric Tubing

AssessmentNursing

DiagnosisScientific




S- “Minsan, nahihirapan akong lumunok”


coughing after drinking

shortness of breath and easy fatigability when eating

needs assistance when drinking and eating

Risk for aspiration related to impaired swallowing due to previous placement of nasogastric tubing

To prevent aspiration and gas distension, a NGT is placed. When this tube is inserted and removed, the tubing leads to trauma of the esophagus, making it difficult for the patient to swallow properly. Aspiration happens when food, liquid, or any material blocks or enters the air passages, leading to compromised breathing.

Short term:After 4 hours of NPI the patient will demonstrate techniques to prevent aspiration such as sitting upright and eating slowly.

Long term:After 3 days of NPI the patient will be free from aspiration.

Assessed patients overall status

Noted amount and rate of food and fluid intake from all sources

Placed in semi fowlers position as appropriate

Advise the patient to maintain an upright position when eating.

Encourage the client to eat food and drink more slowly

To obtained baseline data for future references.

to monitor patients daily intake.

To facilitate movement of diaphragm, improving respiratory effort

To facilitate swallowing

To allow proper breaking down of food for easy swallowing.

Short term:The patient will demonstrate techniques to prevent aspiration such as sitting upright and eating slowly.

Long term:The patient will be free from aspiration.

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Problem # 4: Activity Intolerance Related to Generalized Weakness

AssessmentNursing

DiagnosisScientific




S- “Nanghihina ako lagi” as verbalized by the pt.


weak posture

inability to maintain balance

pale

slow movement

limited range of motion

Activity intolerance related to generalized weakness

Activity intolerance is a condition of the body where there is insufficient physiological or psychological means or capability to endure or complete the required or desired daily activities. Depression can be one of the factors that may increase or contribute to general weakness and may lead to inability of the person to

Short term:After 4 hours of NPI the patient will be able to use and identify techniques to enhance activity

Long term:After 3 days of NPI the patient will demonstrate a measurable increase in activity.

Assess pt’s condition

Note the pt’s report of weakness, fatigue or difficulty accomplishing tasks

Provide adequate rest periods

Increase activity levels gradually

Assist the pt in doing her ADL’s

To obtained baseline data for future references.

To identify more causative or precipitating factors

To prevent fatigue

To conserve energy

To protect the pt from injury

Short term:The patient shall have used and identified techniques to enhance activity.

Long term:The patient shall have demonstrated a measurable increase in activity.

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discomfort

decreased levels of potassium

participate in the activities of daily living. Tolerance to activity wil be compromised for a patient experiencing a disease condition.

Promote comfort measures

Monitor responses to the activity

Encourage pt to change position frequently

Administer medication as ordered

To enhance ability to participate in activities

To indicate the need to alter activity level

To promote wellness and proper circulation

To treat underlying factors

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Problem # 5: Anxiety Related to Lack of Knowledge about the Disease Condition

AssessmentNursing

Diagnosis

Scientific

ExplanationPlanning Intervention Rationale

Expected

Outcome

S = “Ano naba nyan ang mangyayari sakin.?” as verbalized by the pt.

O= Patient manifested

RestlessnessAppears tenseHigh blood

pressure

Patient may manifest:

Increased RR Muscle

Anxiety related to lack of knowledge about the disease condition

Anxiety is a vague uneasy feeling of discomfort or dread accompanied by an autonomic response or a feeling of apprehension caused by anticipation of danger. Due to the lack of knowledge about the disease condition, the patient is not aware or is having difficulty

Short Term:

After 3 hours of Nursing Interventions the patient will be able to identify ways to reduce anxiety.

Long Term:

After 2 days of Nursing Interventions patient will demonstrate reduction of anxiety into

Establish rapport

Assess pt’s condition

Assess for level of anxiety

Explain to the patient, what to expect

To gain clients trust and participation


In order to know the manageability of anxiety and provide appropriate intervention

Limited knowledge of the unknown results may cause anxiety

Short Term:

The patient shall have identified ways to reduce anxiety.

Long Term:

Patient shall have demonstrated reduction of anxiety into manageable levels

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tension Diaphoresis

adjusting about the manifestations of the disease. Thus the patient is afraid on what will happen to her condition as the disease progresses.

manageable levels

Teach the pt proper breathing exercises

Instruct the patient to do diversional activities

Collaborate with other professionals

Administer anti anxiety drugs as ordered

to the patient

Deep breathing exercises can reduce tension

To divert focus to other things

Collaboration promotes the best long range plan to attain success for the health of the patient

Helps to relax the patient if necessary and uncontrollable

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