Tuesday, December 11, 2012

nursing care plan for amebiasis

Nursing Diagnosis: Ineffective airway clearance r/t ineffective cough secondary to bibasal pneumonia Cause Analysis: inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway Reference: Doenges, Moorhouse, & Murr (2010) Nurse’s Pocket Guide: diagnoses, prioritized interventions and rationales, 12th ed., f.A. Davis company Cues Needs Objective/planning Intervention Rationale evaluation Subjective:  Patient states that he has ineffective cough for more than 2 days Objective:  Ineffective cough with absence of sputum  Respiratory rate of 22 breaths per minute  Pallor Activity- exercise pattern At the end of 4 hours of care, the patient will be able to:  Maintain airway patency  Expectorate/clear secretions readily  Encourage deep-breathing and coughing exercises  Monitor vital signs noting changes in blood pressure and heart rate  Elevate head and encourage frequent position changes.  Administer medications as prescribed, mucolytic or expectorants  Avoid placing patient in supine position for extended period  Encourage patient to increase oral intake of fluids  Instruct patient to do some ROM (range of motion) exercises to facilitate healing process  To maximize effort  This promotes maximal inspiration  To prevent atelectasis  To increase the process of expectoration Goal met s patient verbalized minimal coughing and with respiratory rate of 19 breaths per minute and can expectorate secretions already. Nursing Diagnosis: activity intolerance r/t to fatigue associated with interruption in usual sleep pattern because of discomfort secondary to diarrhea Cause Analysis: insufficient physiological and psychological energy to endure or complete required or desired daily activities Reference: Doenges, Moorhouse, & Murr (2010) Nurse’s Pocket Guide: diagnoses, prioritized interventions and rationales, 12th ed., f.A. Davis company Cues Needs Objectives/planning Interventions Rationale evaluation Subjective: “sige na lang ko balik-balik sa CR ug mata-mata, wala pajud ko tulog ug pati paglihok kapuyan nku” as verbalized by the patient Objective:  Pallor  Body weakness  Patient is always lying bed  Needs assistance when ambulating especially when using the bathroom  dysneic Activity-exercise pattern After 4 hours of care, the patient will be able to:  report measurable increase in activity tolerance  reports decrease of fatigue as evidence by activity tolerance (e.g. walking around the room)  plan care to carefully balance rest periods with activities  promote comfort measures like straightening of bed linens  encourage patient to do some ROM (range of motion) exercises to promote activity tolerance  note client reports of weakness, fatigue, pain, difficulty accomplishing tasks and/or insomnia  promote comfort measures and provide for relief of pain  to reduce fatigue  symptoms may be result of/or contribute to intolerance of activity  to enhance ability to participate in activities Goal met as evidenced by patient can ambulate alone in the bathroom without the aid of his watcher and verbalizes “ok-ok naku karun kaysa gaina nga nkapahulay ko ug lihok-lihok gamay” Nursing Diagnosis: impaired physical mobility r/t decreased strength and endurance as evidenced by frequent lying in bed and need of assistance when ambulating secondary to diarrhea Cause Analysis: decreased in strength in muscles in any part of the body can lead to immobilization. Decreased in strength may be due to inefficient circulation of blood to a part of the body (med-surg nursing by Saultzer and Bare) Reference: Doenges, Moorhouse, & Murr (2010) Nurse’s Pocket Guide: diagnoses, prioritized interventions and rationales, 12th ed., f.A. Davis company Cues Needs Objective/planning Intervention Rationale evaluation Subjective: “kapoy mag sige ug balik-balik sa CR ug hawoy maglakaw” as verbalized by the patient Objective:  body weakness  lethargy  Patient is always lying bed  Activity-exercise pattern At the end of 4 hours of care the patient will be able to:  report coping with fatigue as evidenced by verbalized feelings of comfort and increase activity participation  recommend quiet atmosphere; bed rest if indicated stress-need to monitor and limit visitors, home calls, and repeated unplanned interruption  elevate head of bed as tolerated  assess for pain activity  provide client with ample time to perform mobility-related tasks  encourage adequate intake of fluids and nutritious foods   entrance rest helps lower body’s oxygen demand and reduces stress on heart and lungs  enhances lung expansion and maximize oxygenation for cellular uptake  pain restricts the client from achieving a maximal activity level and if often exacerbated by movement (Ackley and Ladwig, 2008, p. 120)  promotes well being and maximizes energy production Goal met as evidenced by patient verbalizes “ok-ok naku karun kaysa gaina nga nkapahulay ko ug lihok-lihok gamay” Nursing Diagnosis: mild pain may be r/t to gastric irritation of gastric mucosa secondary to peptic ulcer disease Cause Analysis: unpleasant sensory and emotional experience arising from actual or potential tissue damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months Reference: Doenges, Moorhouse, & Murr (2010) Nurse’s Pocket Guide: diagnoses, prioritized interventions and rationales, 12th ed., F.A. Davis company Cues Needs Objective/Planning Intervention Rationale evaluation Subjective: “medyo sakit gamay ako tiyan ug suol pud” as verbalized by the patient Objective:  mild epigastric pain of 3  pain scale 0-no pain 1-3 mild pain 4-6 moderate pain 5-7 severe pain 8-9 very severe pain 10- worst possible pain  (+) H. Pylori  Watery stool  Cognitive-perceptual pattern At the end of 30 minutes the patient will be able to:  Report minimal pain or no pain at all in the epigastric area  Maintain bed rest during acute phase  Administer medications such as pain relievers  Encourage patient to have mild warm sponge especially in epigastric area  Give the client soft foods and fluids and let the client rest .  Provide environment conducive to situation  Help patient focus on activities rather than on pain and discomfort by providing diversional activities such as radio and visitors   Minimize stimulation and enhances relaxation  To minimize pain  To relax muscles  Lower miocard work in connection with the work of digestion  To enhance more rest  To focus more on activities and reduce pain Goal unmet as evidenced by patient verbalizes same pain scale of 3 or still has mild pain in epigastric area. Nursing Diagnosis: fluid volume deficit r/t diarrhea secondary to bowel elimination more than 3 times a day Cause Analysis: : refers to excessive elimination of watery stool resulting to loss of electrolytes Reference: Doenges, Moorhouse, & Murr (2010) Nurse’s Pocket Guide: diagnoses, prioritized interventions and rationales, 12th ed., F.A. Davis company Cues Needs Objectives/Planning Intervention Rationale evaluation Subjective: “kaupat naman ko nakalibang rung buntaga” as patient verbalized Objective:  Lethargy/body weakness  Poor skin turgor   Bowel movement of more than 3 times a day  IVF is increased to 140cc/hr  T- 35.5  P- 52  R-22  Bp- 110/80 Nutritional-metabolic pattern After 8 hours of nursing intervention, the patient will be able to:  Increase oral fluid intake of 8 glasses or more  Eat meals with carbohydrate s-rich foods and stool forming foods such as banana  Verbalize elimination of formed stools  Report less diarrheal episodes  Assess v/s noting low blood pressure, severe hypotension, rapid heartbeat, and thread pulses  Administer medications  Encourage patient to eat meals rich in carbohydrates or protein such as BRAT (banana, rice,apple, and toasted bread)  Administer IV fluids as indicated  Emphasize the importance of hand hygiene  Record intake and output  Promote bed rest  Identify foods and fluids that precipitate diarrhea  These changes in v/s are associated with fluid volume loss and/or hypovolemia  (e.g antiemetics or antidiarrheals to limit gastric or intestinal losses; antipyretic to reduce fever)  Foods forming soft-formed stools  To replace lost electrolyte  To prevent the spread of infectious causes of diarrhea such as C. difficile or S. Aureus  To find out the balance of fluids in the body that are needed for daily metabolism  Rest decreases intestinal motility and reduce metabolic rate  Avoiding intestinal irritants promotes bed rest Goal met as evidenced by the patient’s intake is more than 1000cc and output is 750cc and verbalized soft-formed bowel