Assessment S> bakit ako nagka meron ng bukol? as verbalized.
O> verbalization of the problem >state of misconception >vital signs: T- 37.0C P-80 bpm R-22 cpm BP-110/80
Diagnosis Deficient knowledge regarding illness related to unfamiliarity with information resources as evidenced by absence of information
Planning Goal: By the end of the shift the patient will verbalize accurate information about diagnosis Objective: To gain knowledge about diagnosis To have awareness on the condition she have.
Intervention Review patient understanding of the diagnosis
Rationale Validates current level of understanding identify learning needs & provides knowledge for client
Evaluation After 8 hours of nursing intervention the patient was able to verbalize accurate information about the diagnosis
Provide clear & accurate information in factual but in sensitive manner. Answer specifically but do not provide unessential details
Helps with adjustment to the diagnosis of cancer by providing needed information
Provide anticipatory guidance with the patient regarding treatment protocol, length of therapy, & expected results
Accurate & concise information helps to clarify routines
Assessment S>naiirita ako sa natagas sa dede ko as verbalized O>foul odor discharge from left breast >temperature of 39.1C
Diagnosis Risk for infection related to inadequate primary defense as evidenced by destruction of skin barrier & traumatized tissue
Planning Goal: By the end of the shift the patient will know how to prevent infection Objective: To provide proper care to the breast
Intervention Emphasize good personal hygiene
Monitor temperature
Rationale Limits potential sources of infection and secondary overgrowth Early identification of infectious process enables appropriate therapy to start promptly Early intervention may prevent more serious situation
Evaluation After 8 hours of shift the patient understand intervention to prevent and reduce risk of infections. Temperature lowered to 37.0C
Due meds given Paracetamol
Assessment S>kinakabahan ako sa operasyon na gagawin sa akin, as verbalized O> focused on self >body malaise
Diagnosis Fear to upcoming surgery related to situational crisis as evidenced by expressed concerns regarding result
Planning Goal: By the end of the shift the patient will display appropriate range of feelings Objective: To lessened fear To encourage verbalization of feelings
Intervention Encourage patient share thoughts & feelings
Rationale Provides opportunity to examine realistic fears & misconceptions about diagnosis Help patient feel accepted in present condition without feeling judged & promotes sense of dignity and control Provide assurance that patient is not alone or rejected, conveys respect for and acceptance of the person, fostering trust
Evaluation After 8 hours of shift the patient verbalize readiness about upcoming surgery
Provide open environment in which patient feels safe to discuss feelings
Maintain frequent contact with patient. Talk as much as possible
Drugs
1. Co-Amoxiclav
Classification Anti-infective
Action Act by inhibiting the growth & replication of susceptible bacterial growth
2. Ranitidine
H2 histamine receptor antagonist
3. Vitamin C
Water-soluble vitamin
Inhibits histamine at h2 receptor site in parietal cells, which inhibits gastric acid secretion Maintaining proper immune function
Uses Upper respiratory tract infection, lower respiratory tract infection, GUT infections, skin & tissue infections Duodenal ulcer, gastric ulcer, hyper secretory conditions, stress ulcer Treatment and prevention of vitamin C deficiency To correct and prevent vitamin deficiencies
Side Effects Diarrhea, nausea, vomiting
Contraindications Nursing Considerations Hypersensitive Asses for bowel pattern reactions Assess for nephrotoxicity Evaluate therapeutic response, including absence of fever, fatigue, malaise and draining wound Evaluate urine output Teach patient/family to comply with dosage schedule
Headache, dizziness, nausea, vomiting, diarrhea, abdominal pain
Hypersensitivity
Assess mental status Assess GI complaints Administer with meals for prolonged effect Avoid driving, other hazardous activities until patient is stabilized
4. Vitamin B complex
Water-soluble vitamin
It breaks down the nutrient and provides new energy, helps
Anemia, bleeding gums, decreased wound healing, Abdominal pain, constipation, diarrhea, vomiting,
Hypersensitive reactions
With food for better absorption Not to take more than prescribed amount
Hypersensitive reactions
With food for better absorption Not to take more than prescribed amount
5. Pharmine
Amino acids
strengthen the body Used in every cell to build protein
nausea To correct and prevent vitamin deficiencies Anxiety, depression, restlessness, heart papitations Hypersensitivity Watch out for side effects Comply with dosage schedule
