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AssessmentNursing DX/Clinical Problem
Client Goals/Desired Outcomes/ObjectivesNursing Interventions/Actions/Orders and Rationale
*IEvaluation
GoalsInterventions
Subjective Pt states that he cannot walk any farther than the bathroom or the chair without experiencing shortness of breath. Pt states that he was admitted because he was experiencing unusual shortness of breath Objective Chart states chief complaint as “shortness of air” Diagnosis of congestive heart failure Pt demonstrates dyspnea upon exertion and acitivty. Problem Activity Intolerance
Long Term: Pt will demonstrate increased tolerance to activity by discharge.
*Evaluate medications the client is taking to see if they could be causing activity intolerance. Rationale: “Medications such as beta-blockers, lipid- lowering agents, which can damage muscle, and some antihypertensives such as Clonedine and lowering the blood pressure to normal in the elderly can result in decreased functioning.” (Ackley & Ladwig, 2008, p 121) *Assess nutritional needs associated with activity intolerance. Rationale: “The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers.” (Ackley & Ladwig, 2008, p 120) *Provide emotional support and encouragement to the client to gradually increase activity. Rationale: “Fear of breathlessness, pain, or falling may decrease willingness to increase activity.” (Ackley & Ladwig, 2008, p 120) Goal met. Pt demonstrated increased tolerance to activity. Pt was able to ambulate to the room door and back to the bed without any abnormal changes in vitals. Pt stated that he felt stable after ambulating. Continue interventions as listed. Continue to evaluate the pt’s medications to see if they could be causing the activity intolerance. Continue to assess pt’s nutritional needs. Continue to provide emotional support and encouragement so that the pt may feel more confident about resuming activity. R/T Weakness and fatigue Short Term:
Pt will participate in physical activity with appropriate changes in heart rate, blood pressure, and respirations within three days, by [date]. * Monitor vitals before and after any activity, noting any abnormal changes. Rationale: “This can be caused by a temporary insufficiency of blood supply” (Ackley & Ladwig, 2008, p 119) *Assess for pain before activity. Rationale:“Pain restricts the client from achieving a maximal activity level and if often exacerbated by movement. (Ackley & Ladwig, 2008, p 120) *Obtain any necessary assistive devices or equipment needed before assisting in ambulation Rationale: Assistive devices can increase mobility by helping the client overcome limitations.” (Ackley & Ladwig, 2008, p 120) Goal met. Pt was able to participate in physical activity with appropriate vitals changes. His vitals were checked before and after activity and there were no indications of unstable vitals.
Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately.
Post-operative nursing care for patients who underwent TAHBSO would include:
1. Determines patient’s immediate response to surgical intervention.2. Monitor patient’s physiologic status.3. Assess patient’s pain level and administers appropriate pain relief measures.4. Maintains patient’s safety(airway, circulation, prevention of injury)5. Administer medication, fluid and blood component therapy, if prescribed.6. Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy.
This post includes several nursing care plans for post-TAHBSO patients.
1 Acute PainDue to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammation, this damage will cause an inflammation of the nerves when the nerves are affected, there will be the presence of pain.
Assessment
Nursing Diagnosis
Planning NursingInterventions
Rationale Evaluation
Subjective:
The patient may verbalized:
“My incision is hurts”
Acute pain secondary to surgical operation
Short term:
After 4 hours of nursing interventions, the patient’s pain scale will decrease 10/10 to 5/10
Establish rapport
Emphasize ordered diet
Monitor vital signs
Provide comfort measureEncourage deep
To gain trust
To encourage patient not to eat untolerated food
To obtain
Short term:
The patient’s pain scale decreased 10/10 to 5/10
Long term:
Objective:
The patient manifested :
-irritability
-impaired physical mobility
-disturbed sleep pattern
-facial mask
-diaphoresis
-restlessness
-facial grimaces
Long term:
After 1 day of nursing interventions, patient’s pain will diminish and perform activities like side movement and leg bending
breathing
Provide safety measure
Develop communication
review procedures/expectations and tell client when treatment will hurt
Administer analgesics as indicated to maximal dosage as needed
baseline data
To satisfy the confinement of patient
To inhibit pain
To prevent from injury
To alter pain and diminish emotional stress
To reduce concern of unknown and associated muscle tension
To maintain acceptable level of pain.
The patient’s pain diminished and performed activities like side movements and leg bending
2 Hypothermia
Hypothermia is the sudden decrease of temperature. It is due to different factors such as exposure to cool environment, aging or medications. In a surgical procedure hypothermia occurs due to exposure to the cool environment in the OR. Anesthesia also affects body temperature. Inadequate clothing like the OR gown also contributes to heat loss.
Assessment Nursing Diagnosis
Planning NursingInterventions
Rationale Evaluation
S>O
O> The patient may manifest:
reduction in body temperature below normal range
-shivering
-cool skin
-pallor
-slow capillary refill
-cyanotic nail beds
-
Hypothermia
Short term:
After 3 hours of nursing interventions the patient will display core temperature within normal range
Long term:
After 1 day of nursing interventions the patient will demonstrate behaviors to monitor and promote normothermia
> Establish rapport
> Monitor vital signs
> Remove wet clothing and prevent pooling of antiseptic solutions under client in OR
> Wrap in warm blanket
> Avoid use of heat clamps or hot water bottles
>Administer medications to prevent shivering
>Use hyperthermia
>To gain trust
>To obtain baseline data
> These measures protect patient from heat loss
> To promote heat
>Surface rewarming can lead to rewarming shock due to surface vasodilation
> To avoid increasing in temperature
> To warm
Short term:
The patient displayed core temperature within normal range
Long term:
The patient demonstrated behaviors to monitor and promote normothermia
hypertension
-tachycardia
blanket
>Administer fluids during rewarming
> Keep client quiet
> Provide well-balance high calorie diet
> Perform range-of-motion exercises, provide support hose, reposition, do cough/deep breathing exercises, avoid restrictive clothing
> Protect skin by repositioning, applying lotion and avoid direct contact with heating appliance or
patient
> To prevent hypovolemic shock
>To reduce potential for fibrillation in cold heart
> To replenish glycogen stores and nutritional balance
> To reduce circulatory stasis
> impaired circulation can result in severe tissue damage
> To provide heat
blanket
> Provide patent airway with humidified oxygen when used
3 HyperthermiaOrganisms’ releases endotoxin which stimulates the release of pyrogens from the leukocytes resetting the body’s internal thermostat to febrile level then there will be activation of hypothalamus which will result to an increase in epinephrine and heparin, vasoconstriction of cutaneous vessels. Then heat will be produce as peripheral vasodilation results in skin flushing and skin which is warm to touch.
Assessment
Nursing Diagnosis
Planning NursingInterventions
Rationale Evaluation
S> The patient may manifest:
-headache
O> The patient may manifest:
-increase in body temperature
Hyperthermia
Short term:
After 4 hours of nursing interventions the patient will maintain core temperature within normal range
Long term:
After 1 day of nursing
> Establish rapport
> Monitor vital signs
> Monitor body temperature every 4 hours or more often if indicated
> Loosen patient’s clothing
>To gain trust
>To obtain baseline data
> To evaluate effectiveness of interventions
>To promote heat loss through radiation and
Short term:
The patient maintained core temperature within normal range
Long term:
The patient was free from complications such as
above normal range
-flushed skin, warm to touch
-tachycardia
-seizures or convulsions
interventions the patient will be free from complications such as irreversible brain damage and acute renal failure
and remove blankets
> Apply ice bags to axilla or groin and do TSB
> Administer antipyretic as ordered
> Observe patient for confusion or disorientation
> Determine patient’s preference for liquids
> Keep liquids at bedside and within reach
> Monitor intake and output accurately
> Administer I.V fluid as ordered
conduction
>To promote heat loss through evaporation
>To reduce fever
> Changes LOC may result from tissue hypoxia
>Offering patient liquids he prefers promotes adequate hydration
> To allow patient easy access
> To identify changes and progress of the treatment
>These
irreversible brain damage and acute renal failure
> Give patient oresol
>Provide supplement oxygen
> Maintain bed rest
> Provide high-caloric diet, tube feedings or parenteral nutrition
measure prevents excessive loss of water, sodium chloride and potassium
> To replace loss fluid and electrolytes
> To offset increase oxygen demands and consumption
> To reduce metabolic demands
> To meet increased metabolic demands
4 AnxietyDue to upcoming surgical procedure patients are usually experiencing anxiety. The brain signals our body part to initiate responses such as fatigue, nausea and abdominal pain.
Assessment
Nursing Diagnosis
Planning NursingInterventions
Rationale Evaluation
S> The patient may manifest:
- concerns due to change in life event
- fear
- nausea
- abdominal
pain
- fatigue
- sleep disturbance
- urinary hesitancy
O> The patient may manifest:
Anxiety related to situational crisis
Short term:
After 3 hours of nursing interventions the patient will verbalized awareness of feelings of anxiety
Long term:
After 1 day of nursing interventions the patient will appear relaxed and report anxiety is reduced to a manageable level
> Establish rapport
> Monitor vital signs
>Listen attentively; allow patient to express feelings verbally
>Identify and reduce as many environment stressors
>Provide accurate information about the situation
> Provide comfort measures like back rub and soft music
>Use cognitive
>To gain trust
>To obtain baseline data
>To allow patient to identify anxious behaviors and discover source of anxiety
> Anxiety commonly results from lack of trust in the environment
>Helps the patient what is reality based
>To decrease autonomic response to anxiety
>To correct
Short term:
The patient verbalized awareness of feelings of anxiety
Long term:
The patient appeared relaxed and reported that anxiety was reduced to a manageable level
- poor eye contact
- extraneous movement
- restlessness
- irritability
- anorexia
- insomnia
- impaired attention
Trembling, hand tremors
therapy
>Refer patient to professional mental health resources
faulty catastrophic interpretations of physical symptoms
>To provide ongoing mental health assistance
5 FatigueDue to poor physical condition after surgical procedure, body insist demands of nutrition and oxygen that results to fatigue
Assessment
Nursing Diagnosis
Planning NursingInterventions
Rationale Evaluation
S > O Fatigue related to
Short term: >Establish rapport
>To gain trust Short term:
O> the patient manifested:
-Pale skin
-Impaired physical mobility
-Irritability
-Weakness
-Pain= 5/10
-Activity intolerance
-stress
physical condition After 4 hours of
nursing intervention, the patient will demonstrate an increase energy output with presence of fatigue
Long term:
After 3 day of nursing intervention, the patient will perform activities of daily living and participate in desired activities at level of ability
>Monitor vital signs
>Evaluate the need for individual assistance and discuss lifestyle changes imposed by fatigue state
>Establish realistic activity goals with client
>Instruct client in ways to monitor responses to activity and significant signs and symptoms
>To obtain maintenance data
>To determine degree of fatigue
>Enhance commitment in promoting optimal outcomes
>To indicate the need to alter activity level
The patient demonstrated increase energy output without presence of fatigue
Long term:
The patient performed activities of daily living and participate in desired activities at level of activities
6 Sexual DysfunctionDysfunction of the female reproductive system can produce depression and even anxiety. The patient experiences this due to deficient knowledge about the dysfunction and the decrease in sexual desire.
Assessment
Nursing Diagnosis
Planning NursingInterventions
Rationale Evaluation
S > The patient may verbalized:
-problem such as loss of sexual desire
- inability to achieved desired satisfaction
-conflicts involving values
O> the patient manifested:
-alteration in relationship with SO
-Change of interest in self and others
Sexual Dysfunction related to altered body structure and function
Short term:
After 4 hours of nursing interventions the patient will identify stressors in lifestyle that may contribute to the dysfunction
Long term:
After 3 day of nursing interventions the patients will verbalize understanding of individual reasons for sexual problems
>Establish rapport
>Monitor vital signs
> Obtain sexual history including usual patterns of functioning and level of desires
> Be alert to comments of client
> identify current stressors in individual situations
> Avoid making value judgments
>Establish therapeutic nurse-client relationship
>Provide ways to obtain privacy
>To gain trust
>To obtain maintenance data
>To maximize communication and understanding
>Sexual concerns are often disguised as humor, sarcasm, or offhand remarks
> These factors may be producing enough anxiety to cause depression
> They do not help the client
>To promote treatment and facilitate sharing of
Short term:
The patient identified stressors in lifestyle that contributes to the dysfunction
Long term:
The patient verbalized understanding of individual reasons for sexual problems
sensitive information
>To allow sexual expression for individual between partners without embarrassment
7 Risk for InfectionThe skin considered as the first line of defense against any foreign organism when surgical procedure impaired the skin, possible entry of microorganism therefore may cause infection
Assessment
Nursing Diagnosis
Planning NursingInterventions
Rationale Evaluation
S> O
O> the patient manifested:
-Weakness
-Pallor
-with dry and intact
Risk for infection secondary to surgical incision
Short term:
After 4 hours of nursing interventions, the patient shall identify and demonstrate intervention to prevent infection
>Establish rapport
>Monitor V.S.
>Note signs and symptoms of sepsis
>Provide wound healing such as cleaning of
>To gain trust
>To obtain baseline data
>To reduce complication and monitor for infection
>To reduce risk for
Short term:
The patient identified and demonstrated interventions to prevent risk of infection
Long term:
The patient
dressing on the area.
-Pain over the incision
-Irritability
-Presence of intact dressing
-Impaired physical mobility
-diaphoresis
-fever
-seizures
Long term:
After 1 day of nursing interventions, the patient will not have infection
wound
>Provide care, change dressing as needed
>Encourage increase intake of Vitamin C
>Encourage deep breathing exercise
infection
>To promote healing to the incision
>To prevent infection to increase immune resistance
>To increase healing of wound
doesn’t experience infection
8 Risk for Deficient Fluid VolumeDecrease intravascular, interstitial, or intracellular fluid refers to dehydration. Fluid volume deficit or hypovolemia occurs from a loss of body fluid or the shift of fluids into the third space or reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria and increased perspiration. It also occurs to patient who undergone surgery. In an operation the patient is losing too much body fluid through blood loss that can lead to deficient fluid.
Decrease intravascular, interstitial, or intracellular fluid refers to dehydration. Fluid volume deficit or hypovolemia occurs from a loss of body fluid or the shift of fluids into the third space or reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria and increased perspiration. It also occurs to patient who undergone surgery. In an operation the patient is losing too much body fluid through blood loss that can lead to deficient fluid.
Assessment
Nursing Diagnosis
Planning NursingInterventions
Rationale Evaluation
S > The patient may manifest:
- thirst
-weakness
O> the patient manifested:
-decrease urine output
-sudden weight loss
-decrease skin turgor
-dry mucous membranes
Risk for fluid volume deficit
Short term:
After 4 hours of nursing interventions the patient will identify risk factors and appropriate interventions
Long term:
After 3 day of nursing interventions the patients will demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit
>Establish rapport
>Monitor vital signs
> Encourage increase oral fluid intake
> Provide supplemental fluids as ordered
> Monitor intake and output
> Provide safety measures
> Encourage the use of oresol
>To gain trust
>To obtain maintenance data
> To replace loss fluids
>Prevents peak in fluid level
>To ensure accurate picture of fluid status
> Confusion can lead to accidents
>To replace loss electrolyte.
Short term:
The patient identified risk factors and appropriate interventions
Long term:
The patient demonstrated behaviors or lifestyle changes to prevent development of fluid volume deficit
- sunken eyeballs
-change in mental state
