konichiwa!
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
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