NOTRE DAME OF TACURONG COLLEGE COLLEGE OF NURSING NURSING CARE PLAN NAME OF PATIENT: MR. EGGNOG DIAGNOSIS: HYDROECELE PHYSICIAN: DR. BREADSTICK ASSESSMENT INTRA-OPERATIVE NEEDS NURSING DIAGNOS IS GOAL/OBJ ECTIVE NUTRITIONA LMETABOLIC PATTERN Excess Fluid Volume related to the collection of fluid in the sac of scrotum as evidence d by enlargem ent of scrotum. GENERAL : After 8hours of nursing interventio n the patient will be able to stabilize fluid volume. INTERVENTION RATIONALE EVALUATION SUBJECTIVE: No verbal cues OBJECTIVE: -Enlarged both side of his scrotum -Weak looking -Awake -Initial V/S of: Temp:36.8 RR:21RPM PR84BPM BP:120/80 BY: GORDON’S FUNCTIONAL HEALTH THROUGH RATION ALE: Increase d isotonic fluid retention 1. Monitor vital/cognitive signs, watching for changes in blood pressure, heart & respiratory rate. 2. Monitor Input and Output. 3. Obtain patient history to ascertain the probable cause of the fluid disturbance. SPECIFIC: 4. Assess or instruct After 2patient to monitor 3hours of weight daily and nursing consistently, with same interventio scale and preferably at n the the same time of day. patient will 5. Evaluate urine be able to: output in response to 1. diuretic therapy. Verbalize 6. Provide adequate understand activity or position - To monitor closely relevant changes, any increase in vital/cognitive signs will report to physician. - This will measure the amount of fluid loss & intake - Which can help to guide interventions. May include increased fluids or sodium intake, or compromised regulatory mechanisms. - To facilitate accurate Goal partially met, patient was able to stabilize fluid volume with minimal level. ing of individual dietary/ fluid restrictions . 2. Demonstra te behaviors to monitor fluid status and reduce recurrence of fluid excess. changes as able. 7. Institute/instruct patient regarding fluid restrictions as appropriate. measurement and to follow trends. - Focus is on monitoring the response to the diuretics, rather than the actual amount voided. At home, it is unrealistic to expect patients to measure each void. Therefore recording two voids versus six voids after a diuretic medication may provide more useful information. N OTE: Fluid volume excess in the abdomen may interfere with absorption of oral diuretic medications. Medications may need to be given intravenously by a nurse in the home or outpatient setting. - To prevent fluid accumulation in dependent areas. - To help reduce extracellular volume. For some patients, fluids may need to be restricted to 10ml per day. NOTRE DAME OF TACURONG COLLEGE COLLEGE OF NURSING NURSING CARE PLAN NAME OF PATIENT: MR. EGGNOG DIAGNOSIS: HYDROECELE PHYSICIAN: DR. BREADSTICK POST-OPERATIVE ASSESSMENT SUBJECTIVE: Masakit ang tahi sa my itlog ko” OBJECTIVE : - weak looking - facial grimacing noted - Pain scale of 5 in scale of 10. - Restless - Uncomfortabl e - incision on his both side scrotum - Initial v/s of T – 37.1oC BP – 120/90 NEEDS NURSING 3DIAGNOSIS GOAL/OBJECTIVES INTERVENTION RATIONALE EVALUATION Cognitive perceptu al pattern Acute pain related to tissue trauma secondary to hydroecelecto my as evidenced by pain scale of 5 in scale of 10. GENERAL: After 8hours of nursing intervention the patient will be able to report pain is relieved from 0 out of 10 in pain scale. Independent: 1. Monitor vital sign q 4 and record. 2. Carefully assess location of surgical procedure. 3. Accept client description of pain 4. Provide additional comfort such as back rub. 5. Move patient slowly and deliberately, splinting painful area. 6. Maintain semi fowler position as indicated. Dependent: 1. Regulate IVF as - Changes in VS often indicate acute pain and discomfort. - As this can influenced the amount of post op pain experience. - Pain is subjective experienced and cannot be felt by others. - Improves circulation, reduce muscle tension and anxiety associated with pain. - Reduce muscle tension/ Goal met as evidenced by patients verbalization of reduce pain felt from the scale of 4. By: Gordon’ s Function al Health Pattern RATIONALE: Due to the tissue damage brought by surgical incision, pain receptor send impulses to the brain and back to the affected Specific Objective: After 2-3hours of nursing intervention patient will be able to: 1. Verbalized pain is reduced. 2. Verbalized method that provides relief. 3. Demonstrate use of relaxation skills. 4. Appear relaxed mmHg RR – 20cpm PR – 75 bpm and able to have part and that’s rest and sleep. why patient feel 5. Patient will the pain. manifest increase in comfort. ordered. 2. Administer medication as indicated such as analgesic; narcotics. 3.Administer O2 as indicated 2-3 liters guarding, which may help minimize pain of movement. - Facilitate fluid/wound drainage by gravity reducing diaphragmatic irritation/ Abdominal tension and thereby reducing pain. - This provides hydration and main the fluid and electrolyte balance of the patient. - Reduce metabolic rate and intestinal irritation from circulating/local toxin, which aids in pain relief and promotes healing. - This will maintain the oxygen status of the client and supplement the internal and external expiration of different cell. NOTRE DAME OF TACURONG COLLEGE COLLEGE OF NURSING NURSING CARE PLAN NAME OF PATIENT: MR. EGGNOG DIAGNOSIS: HYDROECELE PHYSICIAN: DR. BREADSTICK POST-OPERATIVE ASSESSMENT NEEDS NURSING DIAGNOSIS Subjective: Hindi ko pa masyado kayang tumayo kasi wala pa masyado akong lakas. Objective: -weak looking -lying in bed -awake -irritable -Initial V/S of; T – 37.1oC BP – 120/90 mmHg RR – 20cpm PR – 75 bpm ACTIVITYEXERCISE PATTERN BY: GORDON’S FUNCTION AL HEALTH THROUGH Activity Intolerance related to surgical procedure secondary to hydroecele as evidenced by pt. cannot able to do his Activity of daily living. RATIONALE: Insufficient physiological or psychological energy to endure or complete required or desired daily activities. GOAL/OBJECTIVE S GENERAL: After 8hours of nursing intervention the patient will be able to facilitate maintenance of regulatory mechanics & function. INTERVENTION INDEPENDENT: 1. Note pt. report of weakness, fatigue, pain, difficulty in accomplishing task. 2. Monitor vital/cognitive signs, watching for changes in blood pressure, heart & SPECIFIC: respiratory rate. After 2-3hrs. of 3. Plan care with nursing rest period intervention patient between activities. will be able to : 4. Provide positive -Identify negative atmosphere while factors affecting acknowledging activity intolerance difficulty of the & reduce their situation for the effects when client. possible. 5. Encourage -Used identified expression of RATIONALE -To determine report of complain felt by pt. that have nurse the ability to provide managemen t of care. -To monitor closely relevant changes, any increase in vital/cognitiv e signs will report to physician. -To reduce fatigue. -Help to minimize EVALUATION Goal partially met as evidenced by PT can now maintain regulatory mechanic & function but only at minimal level. techniques to enhance activity tolerance. -Participate willingly in necessary/desired activities. -Report measurable increase in activity tolerance. -Demonstrate a decrease in physiological signs & symptoms of intolerance. feelings contributing to/resulting from condition. 6. Promote comfort measures 7 provide for relief pain. 8. Instruct client in monitoring response to activity and in recognizing signs/symptoms. 9. Encourage client to maintain positive attitude, suggest use of relaxation technique such as deep breathing pattern. 10. Encourage pt. to increase fluid intake frustration & rechannel energy. -To enhance ability to enhance to participate in activities. -To ease the fatigue of pt. and feel relax. -To endicate need that alter activity. -To enhance sense of well being. -To increase energy production & increase output monitoring. PRIORITIZED PROBLEMS: 1. Excess Fluid Volume related to the collection of fluid in the sac of scrotum as evidenced by enlargement of scrotum. (INTRA-OPERATIVE) 2. Activity Intolerance related to surgical procedure secondary to hydroecele as evidenced by pt. cannot able to do his Activity of daily living. ( POST-OPERATIVE) 3. Acute pain related to tissue trauma secondary to hydroecelectomy as evidenced by pain scale of 5 in scale of 10. (POST-OPERATIVE) 4. Disturbed Body Image related to the enlargement of his both scrotum as evidenced by patient verbalization nahihiya ako sa mga kamag anak ko na malaman nila na ganito pala ang sakit ko”.( PRE-OPERATIVE) 5. Anxiety related to the surgical procedure as evidenced by patient verbalization “matakot ako operahan kasi baka kung anu ang mangyari sa akin, baka mamatay pa ko”.( PRE-OPERATIVE)
