NCP- TAHBSO Name: Ralph Raymond A. Agustin BSN-4 ASSESSMENT Subjective: “masakit dito banda” as Verbalized by the patient evidenced by arm pointing at epigastric region. DIAGNOSIS PLANNING Pain related to tissue trauma secondary to (TAH) Total Abdominal Hysterectomy. After 8 hours of nursing interventions the patient’s pain will be relieved. INTERVENTION RATIONALE Independent: Provide Comfort measures Promoting relaxation like helping patient assume enhances coping position of comfort. Suggest abilities. use of relaxation technique and deep breathing exercises. Objective: Encourage early ambulation Conscious and Coherent Weak in Appearance With intact and dry dressing over the incision site. abilities Encourage divertional attention that may reading books. help in coping processes. Provide adequate rest periods With minimal vaginal discharges Able to perform ADL with assistance V/S taken as follows: T: 36.7 P: 70 R: 25 BP: 110/80 Refocuses the activities like waching T.V. or Facial grimace when in pain With guarding behaviour Enhances coping Will help the client in the coping process. Assist client to learn breathing techniques Collaborative: Provide for individualized physical therapy or exercise program that can be continued by the client after discharge. To assist in muscle and generalized relaxation Promotes active, rather than passive, role and enhances sense of control. EVALUATION After 8 hours of nursing interventions Goal is completely met, pain is relived. NCP-HYSTERECTOMY NAME: RALPH RAYMOND A. AGUSTIN BSN-4 ASSESSMENT “Nahihirapan akong umihi” as verbalized by the patient. Objective: V/S taken as follows: T: 36.7 P: 70 R: 25 BP: 110/80 Urine output- <500 ml DIAGNOSIS Urinary retention related to presence of local tissue edema evidenced by bladder distention PLANNING Patient will empty bladder regularly and completely INTERVENTION Independent 1. Note voiding pattern and monitor urinary output. 2. palpate bladder. investigate reports of discomfort, fullness, inability to void. RATIONALE 1. May indicate urinary retention if voiding frequently in small/insufficient amounts (<100 mL). 2. Perception of bladder fullness, distension of bladder above symphysis pubis indicates urinary retention. 3. Provide routine voiding measures, e.g., privacy, normal position, running water in sink, pouring warm water over perineum. 3. Promotes relaxation of perineal muscles and may facilitate voiding efforts. 4. Provide/encourage good perianal cleansing and catheter care (when present). 5. Urinary retention, vaginal drainage, and possible presence of intermittent/indwelling catheter increase risk of infection,especially if patient has perineal sutures. 5. Assess urine characteristics, noting color, clarity, odor. Collaborative 1. Catheterize when indicated/per protocol if patient is unable to void or is uncomfortable. 2. Decompress bladder slowly. 4. Promotes cleanliness, reducing risk of ascending urinary tract infection (UTI). 1. Edema or interference with nerve supply may cause bladder atony/urinary retention requiring decompression of the bladder. Note: Indwelling urethral or suprapubic catheter may be inserted intraoperatively if complications are anticipated. 2. When large amount of urine has accumulated, rapid bladderdecompression releases EVALUATION Goal was met. Patient has emptied bladder regularly and completely 3. Maintain patency of indwelling catheter; keep drainage tubing free of kinks. 4. Check residual urine volume after voiding as indicated. pressure on pelvic arteries, promoting venous pooling. 3. Promotes free drainage of urine, reducing risk of urinary stasis/retention and infection. 4. May not be emptying bladder completely; retention of urine increases possibility for infection and is uncomfortable/painful. NCP – POST OP. NAME: RALPH RAYMOND A. AGUSTIN BSN-4 ASSESSMENT DIAGNOSIS PLANNING Subjective: Patient verbalized “masakit yung tahi dito sa tiyan ko. Mga 5 ang sakit niya pero kaya ko pang tiisin. Sumasakit lang siya pag may kinakain ako o kaya pag masyado akong gumagalaw.” Pain related to abdominal surgical incision (on abdomen with a surgical incision of 4 inches) manifested by verbal report of pain & guarding behavior. Goal: After 8 hours of nursing intervention patient will report a decrease of pain from 5 to 4 and below. Objective cues: Assessed pain scale, dressing is not soaked of bloody discharge, guarding behavior noted when patient moves, facial grimace noted Objective: After 4 hrs. patient will be able to: - demonstrate different relaxation techniques to decrease pain - understand a need for rest period after each activity done. INTERVENTION Diagnostic Assess pain scale Monitor vital signs Therapeutic: -Provide a quiet environment - Assist patient during activities -Administer analgesic if indicated RATIONALE -Helps to determine effectiveness of therapy for pain -To monitor if there are any changes -To minimize stress that patient is experiencing -To minimize feeling of pain -To provide relief through drug interaction Health Teaching: - Emphasize importance rest periods after every activity -Wound healing requires protein & calories for building new cells. The immune system depends on protein & calories to produce antibodies. EVALUATION Goal: After 8 hours of nursing intervention patient did not manifest signs and symptoms of infection during the whole procedure & after the procedure. Objective: After 4 hrs the patient was able to recover from surgery without any complications. -was able to understand importance of wellbalanced diet.
