NCP and Daily Progress

8/8/2019 NCP and Daily Progress

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C. Nursing Managements

Problem #1: Hyperthermia

ASSESSMENT

NURSINGDIAGNOSIS

SCIENTIFICEXPLANATION

OBJECTIVE NURSINGINTERVENTI

ON

RATIONALE EXPECTEDOUTCOME

S >

O > Elevated

temperature

of 37.8 and

above

>Hyperthermi

a

>A fever

occurs when

the thermostat

resets at a

higher

temperature,

primarily in

response to an

infection. To

reach the

higher

temperature,the body

moves blood to

the warmer

interior,

increases the

metabolic rate,

Short Term:

After 4 hrs. of

nursing

intervention,

the patients

body temp.

will reduce

from 39 oC to

37 oC.

Long Term:After 24 hours

of nursing

intervention,

the patients

body temp.

will be

> Establish

rapport

> Monitor and

record vital

signs

> Assess

condition

> Determine

precipitating

factor

> To build trust

and gain

cooperation

> To obtain

baseline data

> To determine

patients

present status

> Identification

and

management of

underlying

causes are

essential to

Short Term:

After 4 hrs. of

nursing

intervention,

the patients

body temp.

shall have

been reduced

from 39 oC to

normal 37 oC.

Long Term:After 24 hours

of nursing

intervention,

the patients

body temp.

shall have


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and induces

shivering. The

"chills" that

oftenaccompany a

fever are

caused by the

movement of

blood to the

body's core,

leaving the

surface and

extremities

cold. Once the

higher

temperature is

achieved, the

shivering and

chills stop.

When the

infection has

been overcome

or drugs such

as aspirin or

maintain

within normal

range of

36.5C to37.5C.

> Assess vital

signs

> Remove

excess

clothing

> Perform TSB

> Provide

adequate rest

> Increase OFI

recovery

> Vital signs

provide moreaccurate

identification of

core

temperature

> This

decreases

warmth and

temperature

> To decrease

temp. by means

of non-

pharmacological

measure

> To conserve

energy and

avoid fatigue

been maintain

within normal

range of

36.5C to37.5C.


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acetaminophen

(Tylenol) have

been taken, the

thermostatresets to

normal and the

body's cooling

mechanisms

switch on: the

blood moves to

the surface and

sweating

occurs.

> Administer

anti-pyretic as

ordered

> To replace

liquid losses and

decreasing body

temp.

> To decrease

temp. by means

of

pharmacological

measure

Problem #2: Acute Pain


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ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIO

N

OBJECTIVE NURSING

INTERVENTION

RATIONALE EXPECTED

OUTCOME

S >

O > Grimace

>restlessness

>irritability

> Acute pain

>W

hen Salmonella

typhi is

ingested, it

may directly

infect the

gallbladder

through the

hepatic duct or

spread to other

areas of the

body through

the

bloodstream

that can lead

to abdominalpain.

Short Term:

After 4 hours

of nursing

intervention,

the patient

will report

pain is

relieved.

Long Term:

After 24 hours

of nursing

intervention,the patient

will appear

relax and able

to sleep and

rest.

> Establish

rapport

> Monitor and

record vital sign,

note non verbal

cues

(restlessness)

> Investigate

report of pain.

> To build

trust and gain

cooperation

> To obtain

baseline data

and useful in

evaluating

verbal

comments

and

effectiveness

of

interventions

> Helpful in

assessing

need for

intervention:

may indicate

Short

Term:

After 4

hours of

nursing

intervention,

the patient

shall have

been report

pain is

relieved.

Long Term:

After 24

hours of nursing

intervention,

the patient

shall have

been appear


5/16

> Provide a quiet

environment and

reduce stressful

stimuli.

> Place in

position of

comfort.

> Assist

with/provide

diversional

activities,

relaxation

technique.

developing

complications

> Promotesrest

> May

decrease

associated

discomfort

> Helps with

pain

management

by redirecting

attention.

relax and

able to sleep

and rest.

Problem #3: Diarrhea


6/16

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIO

N

OBJECTIVE NURSING

INTERVENTIO

N

RATIONALE EXPECTED

OUTCOME

S >

O >

Hyperactive

bowel sounds.

> Diarrhea r/t

enteric

infection.

> It may result

from a variety

of factors,

including

intestinal

absorption

disorders,

increased

secretion of

fluid by the

intestinal

mucosa and

hypermotility

of the

intestines.Diarrhea may

also result

form infectious

processes such

as parasites.

Short Term:

After 4 hours

of nursing

intervention,

the patient

will verbalize

understanding

of health

teachings

given.

Long Term:

After 24 hours

of nursingintervention,

the patient

will decrease

frequency of

defecation.

> Establish

rapport

> Monitor and

record vital

signs

> Obtain a

fecal analysis

> Assess

hydration

status

> To build

trust and gain

cooperation

> To obtain

baseline data

> To identify

the causative

organism

> To prevent

dehydration

and

electrolyteimbalance

> To replace

fluid loss

Short Term:

After 4 hours

of nursing

intervention,

the patient

shall have

been verbalize

understanding

of health

teachings

given.

Long Term:

After 24 hours

of nursingintervention,

the patient

shall have

been

decrease the


7/16

> Encourage

increase OFI

> Teachpatients SO the

importance of

perianal

hygiene after

each bowel

movement

> Auscultate

abdomen

> Restrict solid

food intake as

indicated

> Hygiene

controls

perianal skinexcoriation

and minimizes

risk of spread

of infectious

diarrhea

> To note

presence,

location, and

characteristics

of bowel

sounds

> To allow for

bowel rest/

reduced

intestinal

workload

> To avoid

frequency of

defecation.


8/16

> Provide for

changes in

dietary

> Promote the

use of

relaxation

technique

> Give

medications as

ordered

> Review

causative

factors and

foods/

substances

that

precipitatediarrhea

> To decrease

stress/ anxiety

> To treat

infectious

process,

decrease

gastric

motility, and/

or absorb

water

> To prevent

recurrence


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appropriate

interventions

> Review foodpreparation,

emphasizing

adequate

cooking time

and proper

refrigeration/

storage

> To prevent

bacterial

growth/contamination

Problem #4: Self-care Deficit: Hygiene

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EXPECTED


10/16

DIAGNOSIS EXPLANATIO

N

INTERVENTIO

N

OUTCOME

S > Hindi siya

naghuhugas

ng kamay pag

kumakain as

verbalized by

the SO.

O >

> Self-care

Deficit r/t to

weakness.

>Salmon

ella typhi are

spread by

contaminated

food, drink, or

water.

Following

ingestion, the

bacteria

spread from

the intestine

via the

bloodstream to

the intestinal

lymph nodes,

liver, and

spleen via theblood where

they multiply

and this can

cause malaise.

Short Term:

After 4 hrs of

nursing

intervention,

the patient

will perform

self-care

activities

within level of

own ability.

Long Term:

After 2 days of

nursingintervention,

the patient

will

demonstrate

lifestyle

> Establish

rapport

> Monitor and

record vital

signs

> Promote S.O

participation in

problem

identification

and decision

making

.> Providecommunication

among those

who are

involved in

caring for the

> To build

trust and gain

cooperation

> To obtain

baseline data

> Enhance

commitment

to plan

optimizing

outcomes

> Enhances

coordinationand continuity

of care

Short Term:

After 4 hrs of

nursing

intervention,

the patient

shall have

been perform

self-care

activities

within level of

own ability.

Long Term:

After 2 days of

nursing

intervention,the patient

shall have

been

demonstrate

lifestyle


11/16

changes to

meet self-care

needs.

client

> Assess

abilities andlevel of deficit

> Avoid doing

things for

patient that the

patient can do

for self,

providing

assistance as

necessary

> Aids in

anticipating/

planning formeeting

individual

needs

> To maintain

pts self-

esteem and

promote

recovery

changes to

meet self-care

needs.

Problem #5: Readiness for enhanced fluid balance

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIO

OBJECTIVE NURSING

INTERVENTIO

RATIONALE EXPECTED

OUTCOME


12/16

N N

S > Umiinom

na siya ngaun

as verbalized

by the SO.

O >

> Readiness

for enhanced

fluid balance.

> The S.O is

willing to put

interventions

into action and

at the same

time, the

patient

demonstrated

willingness or

readiness for

enhanced fluid

balance as

evidenced by

increasing

fluid intake.

Short Term:

After 4 hours

of nursing

intervention,

the S.O will

demonstrate

behaviors to

monitor fluid

balance of the

patient.

Long Term:

After 2 days of

nursing

intervention,

the patient willmaintain fluid

volume at a

functional

level as

indicated by

> Establish

rapport

> Monitor and

record vital

signs

> Monitor I/O

as

appropriately,

being aware of

insensible

loses and

hidden

sources of

intake

> Encourage

regular oral

intake

> To build

trust and gain

cooperation

> To obtain

baseline data

> To ensure

accurate

picture of fluid

status

> To maximize

intake and

maintain fluid

balance

Short Term:

After 4 hours

of nursing

intervention,

the S.O shall

have been

demonstrate

behaviors to

monitor fluid

balance of the

patient.

Long Term:

After 2 days of

nursing

intervention,

the patientshall have

been maintain

fluid volume at

a functional

level as


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adequate

urinary output.

> Recommend

restrictions of caffeine

> Instruct S.O

how to

measure and

record I/O if

needed for

home

management

> Prevents

untoward

diuretic effectand possible

dehydration

> Provides

means of

monitoring

status and

adjusting

therapy to

meet changing

needs

indicated by

adequate

urinary output.

VI. Clients Daily Progress

DAYS ADMISSION (26) April 27, 2010 April 28,

2010

April 29,

2010

April 30,

2010*Nursing


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Problems:

1. Hyperthermia

2. Acute Pain

3. Diarrhea

4. Self Care Deficit

(Hygiene)

5. Readiness for

enhance fluid

balance

Vital Signs:

T: (C)

PR: (bpm)

RR: (cpm)BP: (mmHg)

36.6

75

2470/40

35.8

80

20100/70

37.9

98

3090/60

38.2

80

2790/60

35.8

96

2180/60

Dx. Lab

Procedures:

*Urinalysis

Color: Yellow

Clarity: Slightly

Turbid

Specific Gravity:

1.025

PH: 5.0Protein: Trace

Glucose: Negative

RBC: 2-3/ hpf

WBC: 0-3/hpf

Epithelial cells:

few


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*CBC

*Typhidot Test

*Chest PAL

*HbsAg Screening

Mucus Threads:

many

Amorphous: few

Bacteria: few

Casts: Hyaline

cast- 0-2/pf

Hgb: 123

Hct: 0.37

Platelet Count: 210

Positive

Findings:

Bilateral ill- defined infrahilar densities

with paratracheal and hilar nodularities

are noted. Heart is not enlarged.

Diaphragm and bony thorax are

unremarkable.

Impression:

Consider bilateral PPTB. Clinical/ PPD

correlated are suggested.

Non- reactive

127

0.38

230

123

0.37

238

133

0.40

300

Medical

Managements:

IVFs: D5 0.3 Nacl


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1L x FD 150 cc

then 22-23

gtts/minDrugs:

Paracetamol:Ranitidine:

Ampicillin:

Chloramphenicol:

Diet:

DAT except Dark

colored foods

** There was no

prescribed activity

or exercise for the

patient .

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NCP and Daily Progress