DAY 1 (ASSESSMENT) Intervention 1.

Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. 2. Teach the use of non pharmacologic techniques (e.g., relaxation, guide imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures. 3. Placed on moderate high back rest 4. Assisted upon ambulation 5. Encouraged diversional activities 6. Bed rest encouraged 7. Advised to avoid any strenuous activities 8. Advised to secure prescribed medications Rationale Pain is a subjective experience and must be described by the client in order to plan effective treatment

The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

For pain

Intervention

Rationale

1. Provide accurate information about the situation of the client and reasons for surgery. 2. Identify clients perception about the upcoming surgery 3. Promoted accurate information about the operation 4. Calm environment provided 5. Adequate rest period provided 6. Proper hygiene emphasized

To know his own perception about the upcoming surgery It can point to the clients level of anxiety To know more about her upcoming surgery
To provide comfort To To prevent infection

For anxiety

For sleep difficulties

Intervention 1. Encourage the patient to establish a bedtime routine to facilitate transition from wakefulness to sleep. 2. Determine the clients sleep and activity pattern. 3. Encourage him to eliminate stressful situations before bedtime 4. Instruct the patient and significant others about factors (e.g., physiologic, psychologic, lifestyle, frequent work shift changes, excessively long work hours, and other environmental factors) that contribute to sleep pattern disturbances. 5. Encourage verbalization perceptions, and fears. of feelings,

Rationale Rituals and routines induce comfort, relaxation, and sleep

The amount of sleep an individual needs varies with lifestyle, health, and age Stress interferes with a persons ability to relax, rest, and sleep Knowledge of causative factors can enable the client to begin to control factors that inhibit sleep

Open expression of feelings facilitates identification of specific emotions such as anger or helplessness, distorted perceptions, and unrealistic fears

6. Monitor bedtime food and beverage intake for items that facilitate or interfere with sleep.

Milk and protein foods contain tryptophan, a precursor of serotonin, which is thought to induce and maintain sleep. Stimulants should be avoided because they inhibit sleep

Urinary retention Intervention 1. Encourage patient to void every 24 hr and when urge is noted 2. Ask patient about stress incontinence when moving, sneezing, coughing, laughing, lifting objects. Rationale May minimize urinary retention/overdistension of the bladder High urethral pressure inhibits bladder emptying or can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost. Useful in evaluating degree of obstruction and choice of intervention

3. Observe urinary stream, noting size and force.

4. Have patient document time and amount of each voiding. Note diminished urinary output. Measure specific gravity as indicated

Urinary retention increases pressure within the ureters and kidneys, which may cause renal insufficiency. Any deficit in blood flow to the kidney impairs its ability to filter and concentrate substances. A distended bladder can be felt in the suprapubic area. Increased circulating fluid maintains renal perfusion and flushes kidneys, bladder, and ureters of sediment and bacteria. Note: Initially, fluids may be restricted to prevent bladder distension until adequate urinary flow is reestablished. Loss of kidney function results in decreased fluid elimination and accumulation of toxic wastes; may progress to complete renal shutdown.

5. Percuss/palpate suprapubic area.

6. Encourage oral fluids up to 3000 mL daily, within cardiac tolerance, if indicated.

7. Monitor vital signs closely. Observe for hypertension, peripheral/dependent edema, changes in mentation. Weigh daily. Maintain accurate I & O.

8.

Provide/encourage meticulous catheter and perineal care.

Reduces risk of ascending infection

9. Recommend sitz bath as indicated.

Promotes muscle relaxation, decreases edema, and may enhance voiding effort.

Feb. 11, 2013 risk for infection Intervention

1. Assess signs and symptoms of infection especially temperature. 2. Emphasize the importance of hand washing technique. 3. Maintain aseptic technique when changing dressing/ caring wound. 4. Keep area around wound clean and dry. 5. Emphasized necessity antibiotics as ordered of taking

Rationale
Fever may indicate infection. It serves as a first line of defense against infection. Regular wound dressing promotes fast healing and drying of wounds. Wet area can be lodge area of bacteria Pre matured is continuation of treatment when client begins to feel well may result in return of infection

Activity intolerance Intervention

1. Determine patient's perception of causes of fatigue or activity

Rationale
These may be temporary or permanent, physicalor psychological. Assessment guides treatment This aids in defining what patient is capable of, which is necessary before setting realistic goals

2. Assess patient's level of mobility

3. Assess nutritional status.

Adequate energy reserves are required for activity

injury may be related to falls or overexertion Some aids may require more energy expenditure for patients who have reduced upper arm strength (e.g., walking with crutches). Adequate assessment of energy requirements is indicated

4. Assess potential for physical injury with activity 5. Assess need for ambulation aids: bracing, cane, walker, equipment modification for activities of daily living (ADLs).

6. Assess patient's cardiopulmonary status before activity using the following measures Heart rate

Heart rate should not increase more than

20 to 30 beats/min above resting with routine activities. This number will change depending on the intensity of exercise the patient is attempting.

Osthortatic BP changes Need for oxygen with increased activity

Elderly patients are more prone to drops in blood pressure with position changes Portable pulse oximetry can be used to assess for oxygen desaturation. Supplemental oxygen may help compensate for the increased oxygen demands.

Pain
Intervention 1. Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. 2. Teach the use of non pharmacologic techniques (e.g., relaxation, guide imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures. 3. Placed on moderate high back rest 4. Assisted upon ambulation 5. Encouraged diversional activities 6. Bed rest encouraged 7. Advised to avoid any strenuous activities 8. Advised to secure prescribed medications Rationale Pain is a subjective experience and must be described by the client in order to plan effective treatment

The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

For sleep difficulties Intervention 1. Encourage the patient to establish a bedtime routine to facilitate transition from wakefulness to sleep. 2. Determine the clients sleep and activity pattern. 3. Encourage him to eliminate stressful situations before bedtime 4. Instruct the patient and significant others about factors (e.g., physiologic, psychologic, lifestyle, frequent work shift changes, excessively long work hours, and other environmental factors) that contribute to sleep pattern disturbances. 5. Encourage verbalization perceptions, and fears. of feelings, Rationale Rituals and routines induce comfort, relaxation, and sleep

The amount of sleep an individual needs varies with lifestyle, health, and age Stress interferes with a persons ability to relax, rest, and sleep Knowledge of causative factors can enable the client to begin to control factors that inhibit sleep

Open expression of feelings facilitates identification of specific emotions such as anger or helplessness, distorted perceptions, and unrealistic fears

6. Monitor bedtime food and beverage intake for items that facilitate or interfere with sleep

Milk and protein foods contain tryptophan, a precursor of serotonin, which is thought to induce and maintain sleep. Stimulants should be avoided because they inhibit sleep

Feb. 12, 2013- anxiety Intervention Rationale

1. Provide accurate information about the situation of the client and reasons for surgery. 2. Identify clients perception about the upcoming surgery 3. Promoted accurate information about the operation 4. Calm environment provided 5. Adequate rest period provided 6. Proper hygiene emphasized 7. Observe clients behavior

To know his own perception about the upcoming surgery It can point to the clients level of anxiety To more about her upcoming surgery

Deficient fluid volume Intervention

1. Monitor for cardiac manifestations of hypokalemia (e.g., hypotension, tachycardia, weak pulse, rhythm irregularities). 2. Obtain specimens for analysis of altered sodium levels (e.g.,serum and urine sodium, urine osmolality, and urine specific gravity) as indicated. 3. Monitor for neurologic and neuromuscular manifestations of hypernatremia (e.g., lethargy, irritability, seizures, and hyperreflexia).

Rationale
Many cardiac rhythm disorders can result from hypokalemia. It is critical to monitor cardiac function with hypokalemia. Urine analysis provides information about retention or loss of sodium and the ability of the kidneys to concentrate or dilute urine in response to fluid changes. Hypernatremia, as a result of low fluid volume, creates a hypertonic vascular space, which causes water to move out of the cells, including brain cells. This accounts for neurologic symptoms.

4. Monitor for cardiac manifestations of hypernatremia (e.g., tachycardia, orthostatic hypotension).

The heart responds to a loss of fluid by increasing the heart rate to compensate with an increase in cardiac output. Low fluid volume leads to a fall in blood pressure.

5. Weigh daily and monitor trends. 6. Maintain accurate I & O record.

Weight helps to assess fluid balance. Accurate records are critical in assessing the patients fluid balance. Vital sign changes such as increased heart rate, decreased blood pressure, and increased temperature indicate hypovolemia. As her nausea decreases encourage her oral intake of fluids as tolerated, again to replace lost volume.

7. Monitor vital signs as appropriate.

8. Give fluids as appropriate.

Nausea and vomiting

Intervention

1. Position the patient: To prevent aspiration Conscious: semi fowlers,Unconscious: lateral 2. Provide good oral care measures 3. Relieve sensation of nausea by providing any of the following: Ice chips, Hot tea with lemon, Hot ginger ale, Dry toast or crackers, Cold cola beverage 4. Replace fluid-electrolyte loss (oralor intravenous fluid infusion) Observe for potential complications as follows: Dehydration, Thirst (first sign), Dry mouth and mucus membrane, Warm, flushed dry skin, Fever, tachycardia, low BP, Weight loss, Sunken eyeballs 5. Acid-base balance Initially, metabolic alkalosis due to excessive loss of gastric acids

Rationale

6.

If vomiting is incessant /prolonged, metabolic acidosis occurs due to

excessive loss duodenum.

of

bicarbonate

from

7.

Administer antiemetic as ordered by the physician

For sleep difficulties Intervention Encourage the patient to establish a bedtime routine to facilitate transition from wakefulness to sleep. Determine the clients sleep and activity pattern. Encourage him to eliminate stressful situations before bedtime Instruct the patient and significant others about factors (e.g., physiologic, psychologic, lifestyle, frequent work shift changes, excessively long work hours, and other environmental factors) that contribute to sleep pattern disturbances. Encourage verbalization perceptions, and fears. of feelings, Rationale Rituals and routines induce comfort, relaxation, and sleep

The amount of sleep an individual needs varies with lifestyle, health, and age Stress interferes with a persons ability to relax, rest, and sleep Knowledge of causative factors can enable the client to begin to control factors that inhibit sleep

Open expression of feelings facilitates identification of specific emotions such as anger or helplessness, distorted perceptions, and unrealistic fears

Monitor bedtime food and beverage intake for items that facilitate or interfere with sleep

Milk and protein foods contain tryptophan, a precursor of serotonin, which is thought to induce and maintain sleep. Stimulants should be avoided because they inhibit sleep

Feb 13, 2013 pain

Intervention Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. Teach the use of non pharmacologic techniques (e.g., relaxation, guide imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures. Placed on moderate high back rest Assisted upon ambulation Encouraged diversional activities Bed rest encouraged Advised to avoid any strenuous activities Advised to secure prescribed medications

Rationale Pain is a subjective experience and must be described by the client in order to plan effective treatment

The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

Activity intolerance Intervention

Determine patient's perception of causes of fatigue or activity

Rationale
These may be temporary or permanent, physicalor psychological. Assessment guides treatment This aids in defining what patient is capable of, which is necessary before setting realistic goals

Assess patient's level of mobility

Assess nutritional status.

Adequate energy reserves are required for activity

injury may be related to falls or overexertion Some aids may require more energy expenditure for patients who have reduced upper arm strength (e.g., walking with crutches). Adequate assessment of energy requirements is indicated

Assess potential for physical injury with activity Assess need for ambulation aids: bracing, cane, walker, equipment modification for activities of daily living (ADLs).

Assess patient's cardiopulmonary status before activity using the following measures Heart rate

Heart rate should not increase more than 20 to 30 beats/min above resting with routine activities. This number will change depending on the intensity of exercise the patient is attempting. Elderly patients are more prone to drops in blood pressure with position changes Portable pulse oximetry can be used to assess for oxygen desaturation. Supplemental oxygen may help compensate for the increased oxygen demands.

Osthortatic BP changes Need for oxygen with increased activity

Deficient fluid volume Intervention

Monitor for cardiac manifestations of hypokalemia (e.g., hypotension, tachycardia, weak pulse, rhythm irregularities). Obtain specimens for analysis of altered sodium levels (e.g.,serum and urine sodium, urine osmolality, and urine specific gravity) as indicated. Monitor for neurologic and neuromuscular manifestations of hypernatremia (e.g., lethargy, irritability, seizures, and hyperreflexia).

Rationale
Many cardiac rhythm disorders can result from hypokalemia. It is critical to monitor cardiac function with hypokalemia. Urine analysis provides information about retention or loss of sodium and the ability of the kidneys to concentrate or dilute urine in response to fluid changes. Hypernatremia, as a result of low fluid volume, creates a hypertonic vascular space, which causes water to move out of the cells, including brain cells. This accounts for neurologic symptoms.

Monitor for cardiac manifestations of hypernatremia (e.g., tachycardia, orthostatic hypotension).

The heart responds to a loss of fluid by increasing the heart rate to compensate with an increase in cardiac output. Low fluid volume leads to a fall in blood pressure.

Weigh daily and monitor trends. Maintain accurate I & O record.

Weight helps to assess fluid balance. Accurate records are critical in assessing the patients fluid balance. Vital sign changes such as increased heart rate, decreased blood pressure, and increased temperature indicate hypovolemia. As her nausea decreases encourage her oral intake of fluids as tolerated, again to replace lost volume.

Monitor vital signs as appropriate.

Give fluids as appropriate.

Impaired skin
Intervention Rationale

1. Assess noted skin turgos and sensation, described and measure wound and observed changes 2. Demonstrated good skin hygiene: eg. Wash thoroughly and pat dry carefully.

Establishes comparative baseline providing opportunity for timely intervention

Maintaining clean dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin.

3. Instructed family to clean dry clothes preferably cotton fabric

Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection Improved nutrition and hydration will improve skin condition Providing family with alternative solution assists them in optimal healing with less expensive resources Long and rough nails increase risk of skin damage Wound dressings protect the wound and the surrounding tissues

4. Emphasized the importance of adequate nutrition and fluid intake 5. Demonstrated to the family member on how a guava decoction to apply at the wound as alternative disinfectant. 6. Instructed family to clip and file nails regularly. 7. Provided and applied wound dressing properly

headache
Intervention
1. Make sure the duration / episode problems, who have been consulted, and drug and / or what therapy has been used Thorough complaints of pain, record itensitasnya (on a scale 0-10), characteristics(eg, heavy, throbbing, constant) location, duration, factors that aggravate or relieve. Note the possible pathophysiological characteristic, such as brain / meningeal /sinus infection, cervical trauma, hypertension, or trauma.

Rationale

2.

3.

4.

Observe for nonverbal signs of pain, are like: facial expression, posture, restlessness, crying / grimacing, withdrawal, diaphoresis, changes in heart rate / breathing, blood pressure. Assess the relationship of physical factors / emotional state of a person

5.

6. 7. 8.

Evaluation of pain behavior Note the influence of pain such as: loss of interest in life, decreased activity, weight loss. Assess the degree of making a false step in person from the patient, such as isolating themselves. Determine the issue of a second party to the patient / significant others, such as insurance, spouse / family

9.

10. Discuss the physiological dynamics of tension / anxiety with the patient / person nearest 11. Instruct patient to report pain immediately if the pain arises.

12. Place on a rather dark room according to the indication. 13. Suggest to rest in a quiet room.

14. Give cold compress on the head. 15. Massage the head / neck / arm if the patient can tolerate the touch. 16. Use the techniques of therapeutic touch, visualization, biofeedback, hypnosis itself, and

stress reduction and relaxation techniques to another.

17. Instruct the patient to use a positive statement "I am cured, I'm relaxing, I love this life". Instruct the patient to be aware of the external-internal dialogue and say "stop" or "delay" if it comes up negative thoughts. 18. Observe for nausea / vomiting. Give the ice, drinks containing carbonate as indicated.

Feb. 14, 2013

Intervention 1. Assess the clients perception, level of understanding and needs 2. Obtain clients baseline V/S including pain scale

Rationale
To identify and assess the different nursing interventions to be done To assess the effectiveness of nursing interventions and obtain baseline for future comparison Because pain is high subjective

3. Encourage clients verbal report during and after nursing interventions 4. Position the client to where she is comfortable

To provide comfort

5. Teach client deversional activities 6. Administer analgesic as prescribed

To divert attention from pain Alleviate pain

Fatique Intervention 1. Monitor vital signs 2. Allow patient to have adequate rest periods, schedule activities for periods when client has the most energy 3. Encourage patient to do whatever possible such as self care, walking within war premises and interacting with family Rationale To evaluate fluid status and cardiopulmonary response to activity To maximize patient participation

To manage patients limit of activity

4. Instruct methods to conserve energy such as sitting when doing daily care or other activities and taking frequent short rest periods during activities.

To conserve and maximize patients energy

5. Assist patient in self care needs and with ambulation as needed 6. Provide supplemental oxygen

To protect client from injury

Presence of hypoxemia/anemia reduces available oxygen for cellular uptake and contributes to fatique

Activity intolerance Intervention

Determine patient's perception of causes of fatigue or activity

Rationale
These may be temporary or permanent, physicalor psychological. Assessment guides treatment This aids in defining what patient is capable of, which is necessary before setting realistic goals

Assess patient's level of mobility

Assess nutritional status.

Adequate energy reserves are required for activity

injury may be related to falls or overexertion Some aids may require more energy

Assess potential for physical injury with activity Assess need for ambulation aids: bracing,

cane, walker, equipment modification for activities of daily living (ADLs).

Assess patient's cardiopulmonary status before activity using the following measures Heart rate

expenditure for patients who have reduced upper arm strength (e.g., walking with crutches). Adequate assessment of energy requirements is indicated

Heart rate should not increase more than 20 to 30 beats/min above resting with routine activities. This number will change depending on the intensity of exercise the patient is attempting. Elderly patients are more prone to drops in blood pressure with position changes Portable pulse oximetry can be used to assess for oxygen desaturation. Supplemental oxygen may help compensate for the increased oxygen demands.

Osthortatic BP changes Need for oxygen with increased activity

For sleep difficulties Intervention Encourage the patient to establish a bedtime routine to facilitate transition from wakefulness to sleep. Determine the clients sleep and activity pattern. Encourage him to eliminate stressful situations before bedtime Instruct the patient and significant others about factors (e.g., physiologic, psychologic, lifestyle, frequent work shift changes, excessively long work hours, and other environmental factors) that contribute to sleep pattern disturbances. Encourage verbalization perceptions, and fears. of feelings, Rationale Rituals and routines induce comfort, relaxation, and sleep

The amount of sleep an individual needs varies with lifestyle, health, and age Stress interferes with a persons ability to relax, rest, and sleep Knowledge of causative factors can enable the client to begin to control factors that inhibit sleep

Open expression of feelings facilitates identification of specific emotions such as

anger or helplessness, distorted perceptions, and unrealistic fears

Monitor bedtime food and beverage intake for items that facilitate or interfere with sleep

Milk and protein foods contain tryptophan, a precursor of serotonin, which is thought to induce and maintain sleep. Stimulants should be avoided because they inhibit sleep