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Nursing Care Plan

NCP No. 1 Date Identified: February 16, 2012 Date Evaluated: February 16, 2012

Assessment: Subjective: Magpunga lagi ko magginhawa. Objective: - chest excursion noted - use of accessory muscles to breath - Fast, shallow breathing - Nasal flaring - Capillary refill of 5 seconds - Cyanotic nail beds - Irritable - Restless - Vital signs taken as follows: T: P: R: BP: O2 Sat: Diagnosis: Ineffective Breathing Pattern related to General Body Weakness secondary to intense Epigastric Pain.

Planning: Within two hours of nursing care and management, the patient will be able to establish a normal and effective respiratory pattern as to be evidenced by absence of cyanosis, and stable vital signs. NURSING INTERVENTIONS 1. Assess vital signs and record. 2. Auscultate chest. 3. Note emotional responses, such as crying, gasping and reports RATIONALE To provide baseline data for future comparison. To evaluate presence of secretions and evaluate character of breath sounds. Anxiety may be causing or exacerbating acute or chronic

of tingling fingers. 4. Encourage slower and deeper respirations and use of purselip technique. 5. Position patient in moderate high back rest. 6. Maintain calm attitude while dealing with the patient and her significant other. 7. Monitor pulse oximetry and respiratory rate as indicated. 8. Assist patient to assume position of comfort. 9. Provide adequate rest periods in between activities.

hyperventilation. To promote oxygenation and to assist patient in taking control of the situation. To promote lung expansion and to promote physiological and/or psychological ease of maximal inspiration. To limit level of anxiety. To verify maintenance and improvement of respiration and oxygenation. To promote comfort of respiration.

To limit fatigue and to let patient regain energy. Adequate energy helps patient to assume respiration effectively. Collaborative: To promote tissue oxygenation while 1. Administer O2 inhalation at not impairing patients hypoxic lowest possible concentration or drive. as prescribed. 2. Administer analgesic, Evaluation: Goal Met. After two hours of nursing care and management, the patient was able to establish a normal and effective respiratory pattern as to be evidenced by absence of cyanosis, and stable vital sign taken as follows: T: P: R: BP: O2 Sat:

NCP No. 2 Date Identified: February 16, 2012 Date Evaluated: February 16, 2012

Assessment: Subjective: Sakit kayo akong tiyan, naa sa 9 sa anang imong pain scale.

Objective:
Grimace noted Guarding behavior over abdomen Restless Unable to concentrate Reduced interaction with others Irritable With Nasogastric Tube Ultrasound Result: V/S taken as follows: T: P: R: BP:

Diagnosis: Acute Pain related to Inflammation and Autodigestion of the Pancreas secondary to Acute Pancreatitis.

Planning:
Within 2 hours of nursing intervention, the patient will be able to report pain reduction from pain scale of 9 to 4.

Nursing Interventions 1. Assess vital signs and record.


2. Investigate verbal reports of

Rationale To obtain baseline data of information for future comparison. Pain is often diffuse, and unrelenting in acute or hemorrhagic pacreatitis. Severe pain is often the major symptom in a patient with chronic pancreatitis. Decrease stimulation of pancreatic secretions, thereby reducing pain. Reducing abdominal pressure and tension. Sensory stimulation can activate pancreatic enzymes. To promote non-pharmacological management pain management. Promotes relaxation and may enhance coping. To distract attention and reduce tension. To prevent fatigue. Fatigue exacerbates anxiety, which can worsen pain. To reduce concern of the unknown and associated muscle tension.

pain. Noting specific location, onset, characteristic, duration and intensity. 3. Maintain bed rest during acute attack and provide quiet, restful environment 4. Promote position of comfort. 5. Advise significant others to keep environment free of food odors. 6. Encourage to do focused deep breathing exercises. 7. Provide alternative comfort measures including repositioning and back rub. 8. Teach patient to do guided imagery and to listen to smooth music. 9. Provide rest periods. 10. Review procedures/ expectations and tell the patient when treatment may cause pain.

11. Provide frequent oral hygiene care. Collaborative: 1. Administer analgesics as prescribed. 2. Withhold food and fluid, as indicated.

To decrease discomfort from insertion of nasogastric tube.

Patient should be kept noting by mouth status until pain and nausea subside to limit or reduce release of pancreatic enzymes and resultant pain.

Evaluation: Goal Met. After 2 hours of nursing interventions, the patient was able to report pain reduction as evidenced by, Oki-oki na akong tiyan, sakit pero mga naa na sa 3 o 4 sa imong giingon nga pain scale.

NCP No. 4 Date Identified: February 16, 2012 Date Evaluated: February 16, 2012

Assessment: Subjective: Mura jud ko ug kasukaon. Objective: - Facial Pallor noted - Pale conjunctiva and mucus membrane - With Nasogastric Tube - Increased Salivation - Increased Swallowing Noted - Hyperactive bowel sounds of - Ultrasound Result: - Vital signs taken as follows: T: P: R: BP: O2 Sat: Diagnosis: Nausea possibly related to Chemical Contamination of Gastric Mucosa by Pancreatic Exudates secondary to Acute Pancreatitis

Planning: Within the 8-hour shift, the patient will be able to be free of nausea.

Intervention:

Nursing Interventions
1. Assess vital signs and record. 2. Determine degree or severity of nauseated feelings.

Rationale To obtain baseline data of information for future comparison. Nausea may occur in the presence of Indication for the degree of effect on fluid and/or electrolyte balance and nutritional status.

3. Review pain control regimen.

4. Provide ice chips or wet lips with cotton balls soaked with water. 5. Provide osteorized feeding as prescribed including caffeine free diet. 6. Instructed patients significant others to avoid such as perfumes, smoke, and food odors. 7. Provide frequent oral care. 8. Encourage deep, slow breathing. 9. Encourage to use distraction with music and chatting with her significant others. 10.Encourage to wear loosefitting clothes.
11. Review individual factors or

Converting to long-acting opioids or combination drugs may decrease stimulation of the chemotactic trigger zone (CTZ), reducing the occurrence of narcotic-related nausea. To promote comfort and prevent dehydration. Fluid and electrolyte imbalance may cause the nausea. To reduce gastric irritation while maintaining adequate nutrition. These odors may stimulate or worsen nausea. To cleanse mouth and minimize bad taste. To promote relaxation and refocus attention away from nausea. To limit dwelling on unpleasant sensation. Constricted clothing increases intra-abdominal pressure worsening the feeling of nauseated. To provide necessary information for patient to manage own care. Some individuals develop anticipatory nausea(conditioned reflex) that recurs each time she encounters situations that triggers the reflex. To address fluid and electrolyte imbalance.

triggers causing nausea such as side effects of medications and odor, and discuss ways to avoid problem, such as assuming comfortable positions and diversion of attention as mentioned above. Collaborative: 1. Administer Intravenous Solution as prescribed. 2. Administer anti-emetic medication,

Evaluation: Goal Met.After the 8-hour shift, the patient was able to be free of nausea as the patient verbalized: Oki na pod, nawala na ako pagkakasukaon.

NCP No. 5 Date Identified: February 17, 2012 Date Evaluated: February 17, 2012

Assessment: Subjective: Kapoy na jud kayo akong lawas, mga 8 sa 10 ana imong scale. Objective: - drowsy - restless - irritable - Slow sluggish response - Reduced interaction with others - Capillary refill of 5 seconds - Pale conjunctiva and mucus membrane - Complete Blood Count *Hemoglobin: - With Nasogastric Tube - Ultrasound Result: - Vital signs taken as follows:

T: P: R: BP: O2 Sat:

Diagnosis: Fatigue related to Physical Discomfort secondary to Epigastric Pain and NGT Insertion

Planning: Within the 8-hour shift, the patient will be able to perform Activities of Daily Living such as participation in treatment programs and performance desired activities at level of activity.

Intervention:

Nursing Interventions 1. Assess vital signs and record.

Rationale To obtain baseline data of information for future comparison. To evaluate fluid status and cardiopulmonary response to activity.

2. Determine presence or degree of sleep of disturbances. 3. Accept reality of patients fatigue and do not underestimate effect on patients quality of life. 4. Plan interventions to allow individually adequate rest periods.
5. Involve patient and

Fatigue can be a consequence of, and/or exacerbated by sleep deprivation. Patients with fatigue tend to be irritable and lack of desire to participate. Scheduling activities for periods when patient has the energy helps to maximize participation. To plan activities appropriately and at patients convenience. To promote patients control over her own care. To facilitate comfort. To provide diversional and relaxation techniques.

significant other in scheduling planning.

6. Assist with self-care needs. 7. Promote deep breathing exercises, listening to soft

music and guided imagery.

Participating in pleasurable activities can refocus energy and diminish feelings of unhappiness, sluggishness and worthlessness that can accompany fatigue. To help replenish energy, helping patient to regain stamina and strength.

8. Promote adequate rest periods in between activities. Collaborative: 1. Administer O2 inhalation at lowest possible rate or as prescribed. 2. Administer pain medication,

To promote tissue oxygenation while not impairing patients hypoxic drive.

Evaluation: After the 8-hour shift, the patient was able to perform Activities of Daily Living such as participation in treatment program, performance desired activities at level of activity, improved interaction and as patient verbalized, Oo, nakapahulay na jud ko.