DIVINE WORD COLLEGE OF BANGUED Bangued, Abra Department of Nursing Bachelor of Science in Nursing Name: Almera Dei A. Tan Course & Year: BSN 2- A Score: Rating: Date: Instructor’s Signature: NURSING CARE PLAN Assessment Cc: “Nagsakit jay dait ko ma’am, jay parte jay abot ” as verbalized by the patient. Subjective: Pain in the surgical incision - NSD Objective: Facial grimacing Irritability Body weakness Impaired physical mobility Pain scale: 6/10 Nursing Diagnosis Acute vaginal pain related to surgical incision as evidenced by facial grimacing, body weakness and impaired physical mobility. Planning After 6 hours of nursing intervention, the patient will be able to: - Express alleviation of pain from scale of 6 to 3 below. - Verbalize understanding of treatment regimen - Comfortably fall asleep - Demonstrate techniques that enable resumption of activities. - Display behavioral recovery as evidenced by reaching full alert state, responding, and being consoled with appropriate measures. Nursing Interventions Rationale INDEPENDENT: - Rapport is provided with the patient. - The presence and degree of pain is evaluated The patient is advised to limit body movements. Adequate intake of fluids and green leafy vegetables is being encouraged. - Perineal wound care is being provided. DEPENDENT: - Administer medications prior to activity as needed for pain relief. - To gain trust and full cooperation during the pain alleviation period. To aid and assist in alleviation of pain. To lessen the pain being felt by the patient To increase immune resistance. - To avoid risk of infection. - To promote fast recovery or healing to the incision of wound. Evaluation After 6 hours of nursing interventions, the patient was able to: - Expressed alleviation of pain from 6 to 3 below. - Comfortably fall asleep - Perform activities like sitting, standing, bending, and walking. - Verbalized understanding treatment. - Displayed normal behavioral recovery through alertness and responding to measures. DIVINE WORD COLLEGE OF BANGUED Bangued, Abra Department of Nursing Bachelor of Science in Nursing - Displayed strength in physical mobility or fully flexed. DIVINE WORD COLLEGE OF BANGUED Bangued, Abra Department of Nursing Bachelor of Science in Nursing Name: Almera Dei A. Tan Course & Year: BSN 2- A Score: Rating: Date: Instructor’s Signature: NURSING CARE PLAN Assessment Cc: “Matultulala nu kasjay ma’am tapos bigla nga agsangit sunga narigat ko kapatang nu kasjay” as verbalized by the husband of the patient. Subjective: Verbal expression of distress, anger, loss, guilt Objective: Crying Dry tangled hair Lack of energy Dark circles under eyes Change of mood Unable to focus or react properly Nursing Diagnosis Grieving related to Death of fetus/infant as evidenced by crying and verbal expression of distress, anger, loss, and guilt. Planning After series of nursing interventions: - The client participates in self-care activities of daily living as able - The client recognizes the impact/effect of the grieving process and inquires for proper help - The client identifies and expresses feelings freely - The client is able to sleep - The client is able to focus or react properly Nursing Interventions Rationale DEPENDENT: - Allot a private room if the client wants it, with regular contact by care providers. INDEPENDENT: - The free flow of emotional expression is supported. Only the behavior that is dangerous to the well-being of the client/couple (e.g., pulling out IV, using fists to pound on the abdomen) is restricted. - The patient’s nature of movement through the stages of grief is considered; the client is informed that delays in thr grief process or relapses of grief are normal. Expression of grief is influenced by cultural/religious beliefs and expectations, running the gamut from stoic silence to screaming and pounding one’s chest/throwing objects, etc. While expression of loss is cathartic, extended stoicism may impede the mourning process. Giving the client opportunities to express how she feels about this loss. The process of grieving is not usually a fluid progression through the stages to resolution; it is rather a fluctuation between stages and possibly involves skipping of stages. Knowing that grieving is individual helps the couple let each other grieve at his or her own pace. The are no set time limitations for resolving grief, and it is not unusual for the family to be actively dealing with the loss one to two years later. DIVINE WORD COLLEGE OF BANGUED Bangued, Abra Department of Nursing Bachelor of Science in Nursing - The stage of grief being displayed is being recognized (e.g., denial, anger, bargaining, depression, and acceptance) Therapeutic communication skills is used (e.g., Active listening, acknowledgement) but the client’s desire or request not to talk is respected. - What has happened is recognized as often as necessary, the reality of the situation is reinforced and discussion to the client is encouraged - Physical care is rendered as needed, allowed the client to engage at a level of ability. - Anticipated physical and emotional responses to loss is being discussed to the patient. And coping skills is evaluated. - - COLLABORATIVE: - A clergy is contacted according to the family’s wishes. - - Referred the patient for counseling or psychiatric therapy. - If the process of grieving is not completed, grief may become dysfunctional, resulting in behaviors that are disturbing to personal safety and the future of the family and marriage/relationship. The nurse can counsel the couple on the importance of sharing feelings, experiences, and needs in a non-threatening manner and encourage the partner to do the little things that show his partner that he cares for her and will not abandon her. Many families have no earlier struggle in coping with the death of a young person and have a few role models to whom they can relate. The nurse can act as an educator or facilitator concerning ways to act and talk about the experience and explain and correct misconceptions. The couple may experience less stress in their relationship if each can accept how the other feels about the loss and the normality of those reactions. Normal grief may include a period during which activities of daily living are impaired. Assisting in the client’s physical care displays caring and nurturing and helps the client conserve the energy required to meet the demands of the grieving process. Involvement in selfcare maintains self-care maintains self-esteem and a sense of competence. This helps the couple in recognizing the normalcy of their initial and subsequent responses. Grieving is individual, and the extent and nature of the response are influenced by the personality traits, past coping skills, religious beliefs, and ethnic background. Reactions to the loss of a significant person often include temporary impairment of day-to-day function, retreat from social activities, intrusive thoughts, and feelings of yearning and numbness, which can continue for varying periods. The family wants to meet with a minister or spiritual advisor to provide baptism, last rites, cultural rituals, and/or counseling. Religious communities are beneficial as another source of social support, as greater religious participation has been related to increased perception of social support contributing to less grief-related distress for parents. Severe grief response may be noted in older women and those with longer term pregnancies. In addition, carrying the fetus for one or more days after death increases the risk. In cases of pathological grief, ongoing counseling may be necessary to help the individuals identify possible causes of abnormal reaction and resolve the grieving responses. Evaluation After series of nursing interventions: - The client participated in self-care activities of daily living. - The client recognized the impact/effect of the grieving process. DIVINE WORD COLLEGE OF BANGUED Bangued, Abra Department of Nursing Bachelor of Science in Nursing - The client identified and expressed feelings freely The client was able to sleep The client was able to focus or react properly DIVINE WORD COLLEGE OF BANGUED Bangued, Abra Department of Nursing Bachelor of Science in Nursing Name: Almera Dei A. Tan Course & Year: BSN 2- A Score: Rating: Date: Instructor’s Signature: NURSING CARE PLAN Assessment Cc: “Nagsakit ti buo nga tiyan ko, kasla jay uneg ken toy war gapo ditoy dait ko” as verbalized by the patient Subjective: - Client reported pain in the stomach because of the surgical incision - Cesarean delivery Objective: - Pain scale: 7/10 - Facial grimacing - Face is sweating - Guarding behavior Nursing Diagnosis - Acute pain related to disruption of skin and tissue secondary to cesarean section as evidenced by facial grimacing and guarding behavior. Planning - After 4 hours of nursing intervention, patient will verbalize decrease pain intensity from 7/10 to 4/10, patient will participate in prevention measures and treatment, maintain physical well-being and has ability to manage situation. Nursing Interventions Rationale INDEPENDENT: - Rapport is established Vital signs are monitored The presence and degree of pain is evaluated The patient is advised to limit body movements. Skin is inspected on daily basis and changes are observed. Comfortable environment is provided by cleaning bed and proper ventilation Comfort is provided by helping the patient to sit, stand, and lay on bed. DEPENDENT: - Administer medications prior to activity as needed for pain relief. - To have a good nurse-client relationship. To establish baseline data To aid and assist in alleviation of pain. To lessen the pain being felt by the patient. To determine unusual ties and report it to the physician for prompt. Calm environment helps promote likelihood of decreasing pain, anxiety and discomfort. - To avoid injuries or accidents when patient ambulates. - To promote fast recovery or healing to the incision of wound. Evaluation - After 4 hours of nursing interventions, the patient verbalized pain from a scale of 7/10 to 5/10 and can ambulate without assistance. Goal partially met. DIVINE WORD COLLEGE OF BANGUED Bangued, Abra Department of Nursing Bachelor of Science in Nursing Name: Almera Dei A. Tan Course & Year: BSN 2- A Score: Rating: Date: Instructor’s Signature: NURSING CARE PLAN Assessment Subjective: Cc: “my leg hurts so much” as verbalized by the patient Objective: - T: 37 ˚C - Facial grimacing - Guarding behavior - Pain scale rate: 8/10 - Described pain as burning pain, pulsating pain, and painful Nursing Diagnosis - Acute Pain related to post surgery as evidenced by verbalization of pain, facial grimacing, guarding behavior, rated pain in the scale 8 out of 10, and described pain as burning pain and pulsating pain. Planning After 4 hours of nursing intervention: - The patient will describe satisfactory pain control from 8/10 to a level of 4/10 - Display relaxation and signs of comfort such as resting with eyes closed - The patient will have decreased temperature. Nursing Interventions Rationale INDEPENDENT: - Rapport is provided with the patient. - DEPENDENT: - Medications are administered as needed and as prescribed by the physician INDEPENDENT: - Evaluate the effectiveness of the medications administered ae evaluated and any signs and symptoms of side effects are observed. - - - Alternative comfort measures are provided (ice packs, distraction, controlled breathing) Advised the patient to not move his legs - Emotional support is provided and encouraged stress management techniques like deep-breathing techniques, visualization, or guided imagery. Any reports of unusual or sudden pain or deep, progressive, and poorly localized pain unrelieved by the medication administered are investigated. vital signs are assessed, noting tachycardia, hypertension, and increased respiration, even if patient denies pain pain is evaluated regularly, emphasized patient’s - - To gain trust and full cooperation during the pain alleviation period. To effectively treat the level of pain and to help bring down the fever of the patient. To know if the medication is effectively treating the level of pain and if there are unusual reactions of the medicine to the patient Improves general circulation and provides relaxation) The extremity that underwent surgery should remain elevated to lessen the pain. To refocus his attention, promotes a sense of control, and may enhance coping abilities in managing the pain. - May signal developing complications. - May indicate that the pain is going severe. - Provides information about need for or effectiveness of DIVINE WORD COLLEGE OF BANGUED Bangued, Abra Department of Nursing Bachelor of Science in Nursing responsibility for reporting pain/relief of pain completely. interventions. Evaluation After 4 hours of nursing intervention: - The patient described satisfactory pain control from 8/10 to a level of 4/10 - Displayed relaxation and signs of comfort such as resting with eyes closed - The patient had a temperature of 36˚C