Final Part 4

8/8/2019 Final Part 4

1/21

NURSING CARE PLAN

1. Acute pain related to inflammationfected secondary to status post

Ureteroneocystostomy

2. Impaired Urinary Elimination related to reimplantation of the ureter into the

bladder secondary to Ureteroneocystostomy

3. Excess fluid volume related to excess fluid intake as evidenced by intake of 215cc

and output of 115cc secondary to vesicoureteral reflux s/p Ureteroneocystostomy,

Right SSI

4. Impaired skin integrity related to inflammatory response secondary to infection

78


2/21

5. Impaired tissue integrity related to excess fluid volume secondary to vesicoureteral

reflux

Date/

Shift/

Time

Cues Needs Nursing diagnosis Objective of

care

Nursing Intervention Evaluation

January

8, 2010

11am

7-3

Subjective:

sakit kau akong

pantog as

verbalized by the

client.

Objective:

Grimace

face

C

O

G

N

I

T

I

V

E

Acute pain related

pain when urinating

secondary to

vesicourethro

reflux

Within our shift

the client will be

able to relieved

or decreased

from pain from

pain scale of 7

out of 10.

1. Assess for refered pain, as

appropriate

To help determine

possibility of underlying

condition or organ

dysfunction requiring

treatment

2. Administer analgesic, as

indicated, to maximum

GOAL MET!

After 8 hours

span of care

the client

was able to

reduce pain

from 7 out of

79


3/21

Crying

Her hand

placed on

the pain

site

Irritable

Sleep

disturbance

Pain scale

of 7 out of

10

-

P

E

R

C

E

P

T

U

A

L

P

A

T

T

E

R

dosage, as needed

To maintain acceptable

level of pain. Notify

physician if regimen is

adequate to meet pain

control goal.

3. Monitor vital signs.

Vital signs are important

for baseline assessment and

to monitor patients

condition which evaluates

the whole treatment course.

.

4. Accept clients description

of pain. Acknowledge the

10 to 4 out

of 10 as

evidenced by

nga hinay

na xah ug

wala as

verbalizedby

the client.

80


4/21

N pain experienceand convey

acceptance of clients

response to pain.

Pain is subjective

experience and cannot be

felt by others.

5. Provide comfort measures

(eg. Touch, repositioning),

quiet environment, and

calm activities

To promote

nonpharmacological pain

management.

5.encourage adequate rest

periods

81


5/21

To prevent fatigue

6. Note when pain occurs (eg.

Only with ambulation)

To medicate

prophylactically as

appropriate.

82


6/21

Date &Time Cues Need Nursing Diagnosis Objectiveof care Nursing Interventions Evaluation

July

8,

2010

8:00AM

Subjective:

Galisod ug

pangihi ang

akong anak

mao

gipaoperahan

namo siya. as

verbalized by

the father.

Objective:

V/S:

Temp: 36.5 C

PR: 82 bpm

E

L

I

M

I

N

A

T

I

O

N

P

Impaired Urinary

Elimination related to

reimplantation of the

ureter into the bladder

secondary

to



is the reimplantation

of the ureter into the

bladder that is

necessary in cases of

Within 3

days span of

care and

effective

nursing

intervention,

patient will

display

continuous

flow of

urine with

output

adequate for

individual

Independent Nursing Action:

1.Establish rapport

Establishing rapport can gain trust

and cooperation

2. Monitor vital sign

Monitoring the vital signs serves

as the baseline data.

3. Monitor intake and output

Monitoring intake and output will

help us know the fluid balance of the

body

4. Record urinary output, investigate

sudden reduction/cessation of urine

flow.

After 3 days of

rendering effective

nursing intervention

the goal was

completely met as

evidenced by a

continuous flow of

urine with output

adequate for

individual situation.

.

83


7/21

RR: 20 cpm

BP:110/80

mmHg

-loss of

continence

-changes in

amount,

character of

the urine.

-urinary

retention

-incision

noted at the

peritoneum

A

T

T

E

R

N

congenital anomaly or

damage to the ureter.

If there is total

obstruction of the

ureter, it will result an

abnormal flow of

urine that will cause a

problem on the

urinary elimination.

situation. Sudden decrease in urine flow may

indicate obstruction dysfunction or

dehydration.

5. Observe and record color of urine.

Note hematuria and/ or bleeding.

Urine may slightly pink, which

should clear up in 2-3 days after the

surgery.

6. Encourage patient to increase oral

fluid intake

Increasing oral fluid intake can

prevent dehydration and good urine

flow.

7. Assess peripheral pulses, skin

turgor, capillary refill and oral

mucosa. Weigh daily.

Indicators of fluid balance.

84


8/21

Reflects level of hydration and

effectiveness of fluid therapy

replacement.

8. Provide safe & quite environment

Providing a safe & quite

environment can offer conducive

place to rest

Dependent nursing intervention:

1.Administer IV fluids as indicated.

Assissts in maintaining

hydration/adequate circulating

volume and urinary flow.

Date Cues Need Nursing Objective of care Nursing Interventions Evaluation

85


9/21

&

Time

Diagnosis

July

8,

2010

8am

S/O:

(+)nephrotic

syndrome

Increased RR

Intake

exceeds

output

N

U

T

R

I

T

I

O

N

A

L

M

E

T

A

Excess fluid

volume

related to

excess fluid

intake as

evidenced

by intake of

215cc and

output of

115cc

secondary to

vesicoureter

al reflux s/p

Ureteroneoc

ystostomy,

Right SSI

Within 3 days span

of care effective

nursing

intervention the

patient will be able

to:

a. stabilize

fluid

volume as

evidenced

by

balanced I

and O, vital

signs

within

clients

Independent:

1. Record accurate intake and output.

Include hidden fluids such as IV

antibiotics, liquid medications, frozen treats,

ice chips. Measure gastrointestinal losses

and estimate ensible losses, e.g., diaporesis

Low output (less than 400 mL/24hr) may

be first indicator of acute failure, especially

in a high- risk patient. Accurate I&O is

necessary for determining renal function

and fluid replacement needs and reducing

risk of fluid overload.

2.Weigh daily at the same time of the day,

on same scale, with same equipment and

clothing

daily body weight is best monitor of fluid

After 3 days of

rendering

effective

nursing

intervention

the goal was

completely met

as evidenced

by a stabilized

fluid volume as

evidenced by

balanced I and

O, vital signs

within clients

normal limits,

stable weight

86


10/21

B

O

L

I

C

P

A

T

T

E

R

N

R: In VUR,

there is

inability of

the kidney

to absorb

and excrete

electrolytes.

(Medical

Surgical

Nursing,

third

edition,

Williams

and Hopper,

pg 799)

normal

limits,

stable

weight

b. demonstrat

e

dietary/flui

d

restrictions

and

monitor

fluid status

and

recurrence

of fluid

excess

status. A weight gain more than 0.5kg/day

suggest fluid retention

3. Assess skin, face, dependent areas for

edema. Evaluate degree of edema.

edema occurs primarily in dependent

tissues of the body(hands, feet, lumbosacral

area). Patient can gain up to 10lb(4.5kg) of

fluid before pitting edema is detected.

4. Monitor heart rate and BP

Tachycardia and hypertension can occur

because of (1)failure of the kidneys to

excrete urine, (2)excessive fluid

resuscitation during efforts to treat

hypovolemia/hypotension (3)changes in the

rennin-angiotensin system

5. Auscultate lung and heart sounds

fluid overload may lead to pulmonary

demonstrate

dietary/fluid

restrictions and

monitor fluid

status and

recurrence of

fluid excess.

87


11/21

edema and HF evidenced by development

of adventitious breath sounds, extra sounds

6. Assess level of consciousness; investigate

changes in mentation, presence of

restlessness

may reflect fluid shifts, accumulation of

toxins, acidosis, electrolyte imbalances, or

developing hypoxia

Collaborative:

1. Monitor laboratory/ diagnostic studies:

a. BUN, Cr

assess progression and management of

renal function. Cr is a better indictor of

renal function because it is not affected by

hydration, diet, and tissue catabolism

b. Serum sodium

hyponatremia may result from fluid

88


12/21

overload. Hypernatremia indicates total

body water defecit

c. Serum potassium

lack of renal excretion or retention of

potassium to excrete excess hydrogen ions

leads to hyperkalemia, requiring prompt

intervention

d. Hb/Hct

decreased values may indicate

hemodilution (hypervolemia); howver,

during prolonged failure, anemia frequently

develops as a result of RBC loss/ decreased

production.

e. serial chest x-rays

increased cardiac size, prominent

pulmonary vascular markings, pleural

effusion, infiltrates / congestion indicate

89


13/21

acute responses to fluid overload

2. Administer medications as indicated

3.Maintain indwelling catheter as indicated

Catheterization excludes lower tract

obstruction and provides means of accurate

monitoring of urine output

Date &

Time

Cues Need Nursing

Diagnosis

Objective of

care

Nursing Interventions Evaluation

July

9,

2010

Subjective:

Katol ug sakit

akong samad

as verbalized

N

U

Impaired skin

integrity related

to

inflammatory

Within a 3-

day nursing

intervention,

the client


1. Establish rapport


and cooperation

At the end of the 3-

daynursing

intervention, the

client was able to

90


14/21

9:00AM by the patient.

Objective:

V/S:

Temp: 36.2 C

PR: 82 bpm

RR: 20 cpm

BP:110/80

mmHg

Disruption

of skin

surface at the

lower quadrant

of the

abdomen.

Wound

T

R

I

T

I

O

N

A

L

response

secondary

to infection

will be able

to display

improvement

in wound

healing as

evidenced

by:

Intact

skin or

minimized

presence of

wound.

Wound

is less than

10cm in

length.


Monitoring the vital signs serves as

the baseline data.

3.Assessed skin. Noted color, turgor,

and sensation. Described and measured

wounds and observed changes.

Establishes comparative baseline

providing opportunity for timely

intervention.

4. Demonstrated good skin hygiene,

e.g.,wash thoroughly and pat dry

Carefully.

Maintaining clean, dry skin provides

display improvement

in wound healing

as evidenced by:

Minimized presence

of wounds.

Some parts of

wound

have dried up.

Minimized

erythema

Minimized purulent

discharge.

Wounds are still at

91


15/21

10cm in

length.

Localized

erythema

Purulent

discharge

(+)

pruritus on the

site of the

wound.

(+) pain

M

E

T

A

B

O

L

Absence

of redness

or erythema.

Absence

of

purulent

discharge.

Absence

of

itchiness

a barrier to infection. Patting skin dry

instead of rubbing reduces risk of

dermal trauma to fragile skin.

5. Instructed family to maintain clean,

dry clothes, preferably cotton fabric

(any T- shirt).

.

Skin friction caused by stiff or rough

clothes leads to irritation of fragile skin

and increases risk for infection.

6. Emphasized importance of adequate

nutrition and fluid intake

Improved nutrition and hydration

will improve skin condition.

least 10cm in length.

(Continue cleaning

the wound with

disinfectant)

Presence of

Itchiness

(continue instructing

client to avoid

scratching the

wound)

92


16/21

I

C

P

A

T

T

E

7. Demonstrated to the family

members on how to make a guava

decoction to apply to the wound as

alternative

disinfectant

Providing the family with alternative

Solution assists them in optimal

healing with less expensive resources.

8. Instructed family to clip and file

nails regularly.

Long and rough nails increase risk

of skin damage.

93


17/21

R

N

9. Provided and applied wound

dressings carefully.

Wound dressings protect the wound

and the surrounding tissues.



environment can offer conducive place

to rest.

Date &

Time

Cues Need Nursing Diagnosis Objective of

care

Nursing Interventions Evaluation

July

8,

2010

8:00AM

S/Objective:

-damaged

tissue at the

suprapubic

N

U

T

R

I

Impaired tissue

integrity related to

knowledge deficit on

the infected site

secondary to

Within 3

days span of

care and

effective

nursing


1. Establish rapport


and cooperation

After 3 days of

rendering effective

nursing intervention

the goal was

completely met as

94


18/21

area T

I

O

N

A

L

M

E

T

A

B

O

L

I

C

ureteroneocystostomy intervention,

patient will

be a able to

a.

demonstrate

behaviors or

lifestyle

changes to

promote

healing and

prevent

complication

or

recurrence.

b.

display


Monitoring the vital signs serves

as the baseline data.

3.Assessed skin. Noted color, turgor,

and sensation. Described and

measured wounds and observed

changes.

Establishes comparative baseline

providing opportunity for timely

intervention.

4. Demonstrated good skin hygiene,

e.g.,wash thoroughly and pat dry

evidenced by a be a

able to

a. demonstrate

behaviors or lifestyle

changes to promote

healing and prevent

complication or

recurrence.

b.

display progressive

in wound healing

continuous flow of

urine with output

adequate for

individual situation.

.

95


19/21

P

A

T

T

E

R

N

progressive

in wound

healing

Carefully.

Maintaining clean, dry skin

provides a barrier to infection. Patting

skin dry instead of rubbing reduces

risk of dermal trauma to fragile skin.

5. Instructed family to maintain

clean, dry clothes, preferably cotton

fabric (any T- shirt).

.

Skin friction caused by stiff or

rough clothes leads to irritation of

fragile skin and increases risk for

infection.

6. Emphasized importance of

96


20/21

adequate nutrition and fluid intake

Improved nutrition and hydration

will improve skin condition.

7. Demonstrated to the family

members on how to make a guava

decoction to apply to the wound as

alternative

disinfectant

Providing the family with

alternative

Solution assists them in optimal

healing with less expensive

resources.

97


21/21

8. Instructed family to clip and file

nails regularly.

Long and rough nails increase risk

of skin damage.

9. Provided and applied wound

dressings carefully.

Wound dressings protect the

wound

and the surrounding tissues.



environment can offer conducive

place to rest.

98

Documents

Final Part 4