NURSING CARE PLAN PROBLEM: Ineffective breathing NURSING DIAGNOSIS: Ineffective breathing pattern r/t pain as evidenced by hypoventilation

and increased in respiratory rate TAXONOMY: Activity-Exercise pattern CAUSE ANALYSIS: Pain can lead to anxiety and secondary to reflex musculoskeletal spasm, which in turn tend to worsen pain. Inadequate treated pain can provoke physiologic responses that can alter circulation and tissue metabolism and produce a physical manifestation, such as tachycardia, reflective of increased sympathetic activity. ( Carol Mattso, Porth Pathophysiology concepts of altered health status, 6th edition, p. 1130) CUES SUBJECTIVE: STO: OBJECTIVES INTERVENTION Independent Normal reparatory rate is 12-16 bpm in adult Normal respiratory pattern is regular in the healthy adult Pain causes the client to hypoventilate avoid taking deep breath It facilitates lung full expansion LTO: After 3 days of giving care and with appropriate nursing intervention patient was able to maintain an effective breathing as evidence by: - normal rate, rhythm & depth of respiration -absence of hypoventilation RATIONALE STO: After 8 hours of giving care and interventions, patient was able to demonstrate breathing pattern that supports blood gas results with in clients normal parameters EXPECTED OUTCOME

OBJECTIVES >Respiratory rate above normal range >hypoventilation

After 8 hours of giving care Monitor RR, depth, ease of and interventions, patient will respiration be able to demonstrate breathing pattern that supports blood gas results Note pattern of respiration with in clients normal parameters Monitor the presence of pain and provide pain medication for comfort as needed Position client in an upright or semiLTO: fowlers position with lateral After 3 days of giving care position for 60-90 minutes. and with appropriate nursing intervention patient will be Encourage client to take deep able to maintain an effective breaths at prescribe interval or use breathing as evidence by: of incentive spirometer; reinforce - normal rate, rhythm clients progress & depth of respiration -absence of In acute dyspneic state, ensure that hypoventilation the client has received the medications or treatment needed and then stay to provide support.

Anxiety can exacerbate dyspneic panic state. The nurse presence, reassurance, and help in controlling the clients breathing with slower pursed-lip breathing is helpful

references: NCP 6th edition by: Doenges Nurses Pocket Guide 7th edition by: Doenges

PROBLEM: fever NURSING DIAGNOSIS: hyperthermia r/t effect of endogenous pyrogens TAXONOMY: Nutritional-metabolic pattern CAUSE ANALYSIS: endogenous pyrogens (interleukin-1) which comes from macrophages and activated by phagocytosis, endotoxins and others act on the temperature regulating centers in the hypothalamus to elevate the thermostat set-point by inducing the hypothalamus to release prostaglandin E3, which acts on the hypothalamus to evoke fever response. When the set-point is increased, mechanism for raising body temperature is activated. (Focus on pathophysiology by Bullock and Henzie, pp. 264)

References: NCP 6th edition by: Doenges CUES SUBJECTIVES: >patient may verbalized chilling sensation with associate periods of warm or flushed skin OBJECTIVES STO: After 2-3 days in giving nursing intervention, the patient will be able to decrease its temperature by 0.50 C- 10 C until it reaches to normal range. INTERVENTION INDEPENDENT: >monitor temperature (degree &pattern); note chills/ profuse diaphoresis >provide TSB; avoid use of alcohol >note presence/ absence of sweating as body attempts to increase heat loss by evaporation, conduction, and diffusion. OBJECTIVES > increase temperature above normal range > increase RR,>20 bpm >skin warm to touchskin that appears flushed and feels warm (fever abatement) >glassy-eyed appearance >assess neurologic response, noting level of consciousness and orientation; reaction to stimuli; reaction of pupils and presence of posturing seizures >provide cooling blankets >helps to reduce fever COLLABORATIVE: >administer antipyretics (Tylenol, paracetamol) RATIONALE >temperature of 102o F 106o F (38.9o C41.10 C) suggests acute infection disease process. Chills often precede temp. Spikes. >may help reduce fever >evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat >neurologic conditions of an individual may be affected if theres an increase in temperature LTO: After 10 days of giving nursing intervention, the patient was able to her/his maintain core temperature within normal range. EXPECTED OUTCOME STO: After 2-3 days in giving nursing intervention, the patient was able to decrease its temperature by 0.50 C- 10 C until it reaches to normal range.

LTO: After 10 days of giving nursing intervention, the patient will be able to maintain core temperature within normal range.

>it reduces fever by its central action on the hypothalamus

Nurses Pocket Guide 7th edition by: Doenges PROBLEM: Fatigue NURSING DIAGNOSIS: Fatigue r/t severe pain as evidenced by yawning, irritability, and rapid pulse TAXONOMY: Activity-Intolerance Pattern

CAUSE ANALYSIS: The severe pain of biliary colic is produced by obstruction of the cystic duct of the gallbladder. When a store is moving through or is lodged within the n an effort to mobilize the stone through the small duct. This intense pain may be so sever that it is accompanied by tachycardia, pallor, diaphoresis, and prostration (extreme exhaustion). (Medical-Surgical Nursing 5th edition by Ignativicius p.1399)

CUES SUBJECTIVE: >The patient may verbalize complaints of being tired and inability to maintain usual routines.
P- following ingestion of fatty foods, alcohol or caffeine/after meals Q- sharp pain or excruciating pain. R- RUQ that may radiate to right or left scapula. S- severe ( may report 8-10) T- onset: sudden, lasting 2-4 hours

OBJECTIVES STO: After 2-3 days in giving nursing intervention, the patient will be able to verbalize a measurable increase in activity tolerance.

LTO: After 10 days of giving nursing intervention, the patient will be able to have responsibility to self and to demonstrate progressive Activity as tolerated and utilizes (activity) energy saving techniques.

INTERVENTION RATIONALE INDEPENDENT >Monitor the client for evidence of >Extended periods of inactivity may place excess physical and emotional fatigue. the client at risk for excessive fatigue when carrying out desired activities. >Monitor nutritional intake. > Monitoring nutritional intake ensures that the client has adequate energy resources. > Reduce physical discomforts. > Physical discomforts could interfere with cognitive function and self> Arrange Physical activities (e.g., avoid monitoring/regulation of activity. activity immediately after meals). >Arranging physical activities reduces > Encourage alternate rest and activity competition for oxygen supply to vital body periods. functions. >Assist the client to schedule rest periods >This avoids extended periods of either and avoid care activities during activity or exercise. scheduled rest periods. > Rest periods should help restore client > Instruct the client or significant other energy levels. to recognize the signs and symptoms of fatigue. > Symptoms of undue fatigue require a reduction in activity. COLLABORATIVE >Collaborate with the client/family and >Effective interdisciplinary interventions the rehabilitation team. facilitate the clients ability to manage his or her life.

EXPECTED OUTCOME

After giving nursing intervention the patient was able to denies fatigue; no verbal report or observation of being lethargic or listless; denies feeling tired; denies an increased in rest requirements and no verbal report and observation of lack of energy.

OBJECTIVES >yawning >irritability >dark shadows under the eye >uncoordinated movements >lethargic >inability to concentrate >shortness of breath >rapid pulse(>100bpm)

References: NCP 6th edition by: Doenges Medical-Surgical Nursing 5th edition by Ignativicius p.138

Problem: Inability to fall asleep Nursing Diagnosis: Sleep pattern disturbance related to pain secondary to Cholelithiasis Gordons: Sleep-Rest Pattern Cause Analysis: This problem can occur when an individual felt pain or sensation of pressure in the epigastrium or right upper quadrant, which may radiate to the right scapular area or right Shoulder. (Ref. Lippincotts Pocket Manual of Nursing Practice pg. 198) CUES Subjective: OBJECTIVES INTERVENTIONS Independent Assess clients sleep patterns and usual bedtime rituals and incorporate these into the plan of care Observe clients meds, diet and caffeine intake Provide measure to assist with sleep Keep environment quite RATIONALE Expected outcome

STO: Within 8 hours of giving Patient may report di ko appropriate nursing care, katulog tungod sa sakit pt. will have less nga aking gakabati. uninterrupted asleep and decreased pain as P- following ingestion of evidenced by a sleeping fatty foods, alcohol or 5-6 hours with a pain caffeine/after meals scale of 3-4/10
Q- sharp pain or excruciating pain. R- RUQ that may radiate to right or left scapula. S- severe ( may report 8-10) T- onset: sudden, lasting 2-4 hours

LTO Within 3 days of care, the Inform client of the normal patients pain/discomfort changes in sleep pattern that occur will be totally diminished with aging and patient will report of Discourage intake of foods and sleep period of 6-8 hours fluids high in caffeine (chocolate, coffee, tea) especially in the night Collaborative:

STO: Usual sleep patterns are individual, After 8 hours of giving data colleted through a appropriate nursing care, pt comprehensive and holistic had less uninterrupted asleep assessment are needed to achieve the and decreased pain as etiology of the disturbance evidenced by a sleeping 5-6 hours with a pain scale of 34/10 Difficulty sleeping can be a side effects of meds given, caffeine intake can interfere with sleep. Noise can increase sleep deprivation. LTO Critical care nurses can take after 3 days of care, the patients pain/discomfort was effective action to promote sleep totally diminished and patient In order to reduce concerns about will report of sleep period of 6quantity of sleep necessary to 8 hours maintain health This can promote excessive urination which may hinder proper night rest. Administering analgesia to an

Objectives: Administer analgesic as Fatigue ordered and evaluate effectiveness Facial grimace Give Meperidine as indicated Guarded movement Irritability Reference: Gulanick, et.al. Nursing Care Plans, Nursing Diagnosis and Intervention 3rd edition

individual helps to control pain Provides temporary relief of pain, enhances pts ability to cope with situation.

PROBLEM: Pain NURSING DIAGNOSIS: Altered comfortt related to obstruction/ductal spasm secondary to choleliliatiasis. TAXONOMY: Cognitive-Perceptual Pattern CAUSE ANALYSIS: If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute cholecystitis). The patient may have biliary colic with excruciating upper abdominal pain that radiates to the back or shoulder. Such a bout of biliary colic is caused by contraction of the gallbladder, which release bile because of obstruction by the stone. CUES SUBJECTIVE:
P- following ingestion of fatty foods, alcohol or caffeine/after meals Q- sharp pain or excruciating pain. R- RUQ that may radiate to right or left scapula. S- severe ( may report 8-10) T- onset: sudden, lasting 24 hours

OBJECTIVE STO: After 8 hours of giving nursing intervention, the patient will be able to demonstrate use of relaxation skills and diversional activities as indicated for individual situation

NURSING INTERVENTIONS

RATIONALE

INDEPENDENT: .Observe and document location, Assists in differentiating cause of pain, severity (0-10 scale), and character and provides information about disease of pain progression/ resolution, development of complications, and effectiveness of interventions. Promote bedrest, allowing patient Bed rest in low-Fowlers position to assume position of comfort. reduces intra-abdominal pressure; however, patient will naturally assume least painful position.

EXPECTED OUTCOMES After 8 hours of giving nursing intervention, the patient was able to demonstrate use of relaxation skills and diversional activities as indicated for individual situation

OBJECTIVE: Reports of pain Facial grimace Changes in BP and pulse

LTO: After 2-3 days of initiating effective nursing intervention, the patient will be able to demonstrate comfort as evidenced by movement without grimacing, by requesting analgesics no more frequently than ordered and by statement

Encourage expression of feelings Verbalization allows outlet for about pain. emotions and may enhance coping mechanisms. After 2-3 days of initiating effective nursing intervention, Use soft/ cotton linens; calamine Reduces irritation/ dryness of the skin the patient was able to lotion, oil (Alpha Keri) bath; cool/ and itching sensation. demonstrate comfort as moist compresses as indicated. evidenced by movement without grimacing, by

Diaphoresis Guarding behavior

that the pain is tolerable and not Encourage use of relaxation Promotes rest, redirects attention, may requesting analgesics no more interfering with rest or physical techniques, e.g., guided imagery, enhance coping. frequently than ordered and by therapy. visualization, deep-breathing statement that the pain is exercises. Provide diversional tolerable and not interfering activities. with rest or physical therapy. Make time to listen to and maintain Helpful in alleviating anxiety and frequent contact with patient. refocusing attention, which can relieve pain.

Referrence: Kozier, et. al .Fundamentals of Nursing, 5th edition. Doenges, et. al. Nursing Care Plans, 6th edition. Problem: Itching Nursing Diagnosis: Risk for impaired skin integrity related to pruritus secondary to obstructive jaundice. Taxonomy: Nutritional-Metabolic Pattern Cause Analysis: In a person with obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excessive bile salts to accumulate in the skin. This accumulation of bile salts leads to pruritus (itching) or a burning sensation. (Medical-Surgical Nursing by Ignativicius p. 1397). This predisposes the individual to impaired skin integrity. CUES OBJECTIVES I NTERVENTIONS RATIONALE EXPECTED OUTCOME SUBJECTIVE: STO: 1) Health Teachings: The client may verbalized After 30 minutes of effective a) Advise the client not to take -hot baths stimulates itching. After 30 minutes of effective health itching both in upper and health teaching, the patient will hot baths. teaching, the patient was able to lower extremities. be able to verbalized b) Advise the client against -it stimulates itching and verbalized understanding as understanding as evidenced by scratching. increases risk for infection. evidenced scratching episodes and scratching episodes and c) Explain the cause of itching. increased comfort. increased comfort. d) Avoid clothing that -for clients further continuously rubs the skin such understanding. as tight belts, nylon stockings -(this are guidelines to prevent and panty hose. dryness of the skin) LTO: e) Do not apply rubbing -to prevent dry skin OBJECTIVES: Within 3 days of effective alcohol, astringents or other Within 3 days of effective nursing *yellowish, itchy skin nursing intervention, the patient agents. intervention, the patient was able *scratching will be able to maintain clean, f) Avoid caffeine and alcohol to maintain clean, moist skin, free *restlessness moist skin, free from scratching ingestion. from scratching and the patient *irritability and the patient verbalizes g) Encourage client to keep the verbalizes increased comfort. increased comfort. fingernails trimmed short, with rough edges filed. h) Tell the clients to wear

mitters or splints at night. 2) Keep bedclothes dry, use nonirritating materials, and keep bed free from wrinkles, crumbs, and so forth. 3) Therapeutic baths (balneotherapy) with colloidal oatmeal preparations or tar extracts. 4) Suggest use of ice, colloidal bath, lotions. COLLABORATIVE: -to reduce skin damage

-it can help to prevent inadvented scratching during sleep. -this may give temporary relief. -to decrease irritable itching.

1) Give antihistamine as prescribed and closely monitor the clients response to May reduce itching. The therapy. clients response should be closely monitored so that dosages can be adjusted as needed. References: Nurses Pocket Guide 10th edition by Doenges pp. 492-495 Nursing Diagnosis and Intervention by Campbell pp.922-923 Medical Surgical Nursing 5th edition by Ignativicius p. 1576

Problem: Risk for fluid volume deficit Nursing Diagnosis Risk fpr fluid volume deficit related to excessive losses through gastric suction; vomiting, distension, and gastric hypermotility Gordons: Nutritional metabolic pattern Cause Analysis: CUES OBJECTIVES INTERVENTIONS RATIONALE Expected outcome

Subjective: The patient may verbalize excessive vomiting

STO: After 8 hours of giving effective nursing interventions, the patient will be able to display positive response regarding health teachings.

Independent Maintain accurate record of I&O, noting output less than intake, increased urine specific gravity. Assess skin/mucous membranes, peripheral pulses, and capillary refill. Monitor for signs/symptoms of increased/continued nausea or vomiting, abdominal cramps, weakness, twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, depressed respirations. Eliminate noxious sights/smells from environment.

Provides information about fluid status/circulating volume and replacement needs.

STO
After 8 hours of giving effective nursing interventions, the patient was able to display positive response regarding health teachings.

Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride.

Reduces stimulation of vomiting center. Decreases dryness of oral mucous membranes; reduces risk of oral bleeding. Reduces trauma, risk of bleeding/hematoma formation

Objectives: V/S TBPPDry skin Dry mucous membrane Poor skin turgor Decrease urine output (500mlper day) Vomiting LTO: After 3 days of giving effective nursing interventions, the patient will be able to demonstrate adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output and absence of vomiting.

Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants. Use small-gauge needles for injections and apply firm pressure for longer than usual after venipuncture. Collaborative Keep patient NPO as necessary. Insert NG tube, connect to suction, and maintain patency as indicated. Administer antiemetics, e.g., prochlorperazine (Compazine). Review laboratory studies, e.g., Hb/Hct, electrolytes, ABGs (pH), clotting times. ADMINISTER IV FLUIDS, ELECTROLYTES, AND VITAMIN K.

Decreases GI secretions and motility. Provides rest for GI tract. Reduces nausea and prevents vomiting. Aids in evaluating circulating volume, identifies deficits, and influences choice of intervention for replacement/correction. MAINTAINS CIRCULATING VOLUME AND CORRECTS IMBALANCES.

LTO:
: After 3 days of giving effective nursing interventions, the patient was able to demonstrate adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output and absence of vomiting

Reference: Gulanick, et.al. Nursing Care Plans, Nursing Diagnosis and Intervention 3rd edition Davis, E.A. Nursing Care Plans

Problem: Knowledge deficit Nursing Diagnosis Knowledge deficit related to unfamiliarity with information resources Gordons: Cognitive-Perceptual Pattern Cause Analysis: The total range of what has been learned or perceived as true is knowledge. It is accumulated through experience, study, or investigation. Culture, socio-economic factors, age affects knowledge or perception (p39, General Sociology Focus on the Philippines 3rd Ed. by Panopio, Raymundo, Cordero-MacDonald) CUES Subjective: OBJECTIVES STO: After 8 hours of giving effective nursing interventions, the patient will be able to verbalize understanding about his condition and enumerate the factors that aggravate the condition. LTO: After 8 hours of giving effective nursing interventions, the patient would correctly perform necessary procedures and explain reasons of actions demonstrate/initiate necessary lifestyle changes and participate in treatment regimen. INTERVENTIONS Independent Provide explanations of/reasons for test procedures and preparation needed. Review disease process/prognosis. Discuss hospitalization and prospective treatment as indicated. Encourage questions, expression of concern. Review drug regimen, possible side effects. RATIONALE . Information can decrease anxiety, thereby reducing sympathetic stimulation. Provides knowledge base from which patient can make informed choices. Effective communication and support at this time can diminish anxiety and promote healing. Gallstones often recur, necessitating longterm therapy. Development of diarrhea/cramps during chenodiol therapy may be dose-related/correctable. Note: Women of childbearing age should be counseled regarding birth control to prevent pregnancy and risk of fetal hepatic damage. Obesity is a risk factor associated with cholecystitis, and weight loss is beneficial in medical management of chronic condition. Prevents/limits recurrence of gallbladder attacks. LTO: After 8 hours of giving effective
STO

Expected outcome

After 8 hours of giving effective nursing interventions, the patient will be able to to verbalize understanding about his condition and enumerate the factors that aggravate the condition.

Objectives: Questions; request for information Statement of misconception Inaccurate followthrough of instruction Development of preventable complications

Discuss weight reduction programs if indicated

Instruct patient to avoid food/fluids high in fats (e.g., whole milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans, onions, carbonated beverages), or gastric irritants (e.g.,

spicy foods, caffeine, citrus).

LTO: After 3 days of giving effective nursing interventions, the patient will be able to

nursing interventi would correctly perform necessary procedures and explain reasons of actions demonstrate/initiate necessary lifestyle changes and participate in treatment regimen. ons, the patient will be able to

Reference: Gulanick, et.al. Nursing Care Plans,

Problem: Lack of appetite Nursing Diagnosis: Altered nutrition less than body requirements related to self-imposed o r prescribed dietary restrictions, nausea/vomiting, dyspepsia, pain Gordons: Nutritonal metabolic pattern Cause Analysis: CUES Subjective: OBJECTIVES INTERVENTIONS RATIONALE STO
After 8 hours of giving effective nursing interventions, the patient was able to report relief of nausea/vomiting, and pain.

Expected outcome

Independent STO: After 8 hours of giving effective nursing Estimate/calculate caloric intake. a Keep comments about appetite to The patient may interventions, the patient will minimum. verbalize excessive be able to report relief of vomiting and pain. nausea/vomiting. Weigh as indicated.
P- following ingestion of fatty foods, alcohol or caffeine/after meals Q- sharp pain or excruciating pain. R- RUQ that may radiate to right or left scapula. S- severe ( may report 8-10) T- onset: sudden,

Identifies nutritional deficiencies/needs. Focusing on problem creates a negative atmosphere and may interfere with intake. Monitors effectiveness of dietary plan. Involving patient in planning enables patient to have a sense of control and encourages eating. Useful in promoting appetite/reducing nausea. A clean mouth enhances appetite. May lessen nausea and relieve gas. Note: May be contraindicated if beverage causes

Consult with patient about likes/dislikes, foods that cause distress, and preferred meal schedule. LTO: After 3 days of giving effective nursing interventions, the patient will be able to demonstrate progression toward desired weight gain or maintain Provide a pleasant atmosphere at mealtime; remove noxious stimuli. Provide oral hygiene before meals. Offer effervescent drinks with meals, if tolerated.

LTO: After 3 days of giving effective nursing interventions, the patient

lasting 2-4 hours

weight as evidenced by the absence of nausea/vomiting. Assess for abdominal distension, frequent belching, guarding, reluctance to move. Ambulate and increase activity as tolerated.

gas formation/gastric discomfort. Nonverbal signs of discomfort associated with impaired digestion, gas pain. Helpful in expulsion of flatus, reduction of abdominal distension. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility 9e.g., pneumonia, thrombophlebitis).

was able to demonstrate progression toward desired weight gain or maintain weight as evidenced by the absence of nausea/vomiting.

Objectives:
-Dry skin -Dry mucous membrane -Poor skin turgor -Vomiting -anorexia -wt. loss

Collaborative Consult with dietitian/nutritional support team as indicated. Begin low-fat liquid diet after NG tube is removed.

Useful in establishing individual nutritional needs and most appropriate route. Limiting fat content reduces stimulation of gallbladder and pain associated with incomplete fat digestion and is helpful in preventing recurrence. Meets nutritional requirements while minimizing stimulation of the gallbladder.

Advance diet as tolerated, usually low-fat, high-fiber. Restrict gasproducing foods (e.g., onions, cabbage, popcorn) and foods/fluids high in fats (e.g., butter, fried foods, nuts). Administer bile salts, e.g., Bilron, Zanchol, dehydrocholic acid (Decholin), as indicated. Monitor laboratory studies, e.g., BUN, prealbumin, albumin, total protein, transferrin levels. Provide parenteral/enteral feedings as needed Reference: Gulanick, et.al. Nursing Care Plans,

Promotes digestion and absorption of fats, fat-soluble vitamins, cholesterol. Useful in chronic cholecystitis. Provides information about nutritional deficits/effectiveness of therapy. Alternative feeding may be required depending on degree of disability/gallbladder involvement and need for prolonged gastric rest.