Assessment

NURSING Nursing
CARE PLAN FOR SKINDiagnosis Planning Intervention Rationale Evaluation
" Subjective: Impaired skin integrity Following a three day Assessed skin noted color, Establish comparative baseline At the end of the three day
“May mga sugat related to nursing intervention the trigger, and sensation. providing opportunity for timely nursing intervention, the
ako” as verbalized by inflammatory client will be able to Described and measured intervention. client was able to display
the patient. response secondary to display improvement in once and observed changes. improvement in one healing
infection wood healing as as evidenced by:
Objective: evidenced by:  Demonstrated good skin  Maintaining clean dry skin  Minimize presence of
Disruption of the hygiene, e.g., Wash provides a barrier to infection. wounds.
skin surface at the  Intact skin or thoroughly and pat dry Patting skin dry instead of rubbing  Several wounds have
lower extremity. minimize presence of carefully. reduces dermal trauma to fragile dried up.
wound skin.  Minimizes erythema.
Wound is 6mm in  Instructed family to  Skin friction caused by Steve or  Minimized purulent
diameter.  Wound is less than 6 maintain clean, dry half closely to irritation of fragile discharged.
mm in diameter clothes, preferably skin and increases risk for  Wounds are still at least
Localized erythema cotton fabric. infection. 6mm in diameter.
 Absence of redness  Emphasize importance  Improve nutrition and hydration (Continue cleaning the
Purulent discharge or erythema of adequate nutrition will improve your skin condition. wound with
and fluid intake. disinfectant).
(+) pruritus on the  Absence of purulent  Demonstrated to the  Providing the family with
side of the wound discharge family member on how alternative solution assist them in  Presence of itchiness.
to make a guava optimal healing with less  (Continue instructing
(+) pain  Absence of itchiness decoction to apply the expensive resources. client to stop scratching
world as alternative the wound.)
disinfectant.
 Instructed family to  Long and rough nails increase risk
keep and file nails of skin damage.
regularly.
 Provided an applied for  Wound dressing protect the
addressing carefully. wound and the surrounding of
tissue
NURSING CARE PLAN FOR ACUTE PAIN
Assessment Nursing diagnosis Planning Intervention Rationale Evaluation
Mr. C. is a 57 year Physical Acute Pain related Comfort Level as Pain Management Pain is a subjective Outcomes partially
old businessman Examination to tissue injury evidenced by •Perform a comprehensive experience and must be met.The client verbalizes
who was admitted to Height:188 cm(6'3") secondary to •Substantial report of assessment of pain to described by the client in pain and discomfort,
the surgical unit for Weight:90.0 kg(200 surgical satisfaction with pain include location, order to plan effective requesting analgesics at
treatment of a 1b) intervention (as control characteristics, onset, treatment. onset of pain. States “the
possible is Temperature:37C(98 evidenced •Turn,cough,and deep duration, frequency, pain is a 2”(on a scale
strangulated inguinal .6F) by restlessness, breathe with a quality, intensity or of 1-10) 30 minutes after
hernia. Two days ago Pulse:90 BPM pallor; elevated minimum of discomfort severity,and precipitating analgesic administration.
he had a partial Respirations:24/ pulse,respirations, by 2nd factors of pain. Requests analgesic 30
bowel resection. minute and systolic blood postop day •Consider cultural Each person experiences and minutes before
Postoperative orders Blood pressure: pressure, dilated Pain Control as influences on pain expresses pain in an ambulation. Remains
include NPO, 158/82 mm Hg pupils, and report evidenced by often response (e.g,cultural individual manner using a hesitant to cough and
intravenous infusion Skin pale and moist, of 7/10 demonstrating ability to beliefs about pain may variety of sociocultural deep breathe even
of D5 1/2 NS at 125 pupils dilated. abdominal pain) •Use analgesics result in a stoic attitude). adaptation techniques. following analgesic
mL/hr left arm, Midline abdominal appropriately administration on 2nd
nasogastric to lower incision, sutures dry •Use non analgesic •Reduce or eliminate Personal factors can postop day. States
intermittent suction. and relief measures factors that precipitate or influence pain and pain willingness to try
Mr. Mendez is in a intact. •Report symptoms to increase Mr.C's pain tolerance. Those factors that relaxation techniques,
dorsal recumbent Diagnostic Data health care professional experience(fear, fatigue, may be precipitating or however,has not
position and is Chest x-ray and •Use preventive monotony, and lack of augmenting pain should attempted to do so
attempting to draw urinalysis measures knowledge). reduced or eliminated to individualized for each
up his legs. He negative,WBC Pain Level as evidenced enhance the overall pain client.
appears restless and 12,000 by slight to no management
is complaining of •Reported pain •Teach the use of program.
abdominal pain (7 of •Protective body nonpharmacologic The use of noninvasive pain
scale of 1 to 10 positioning techniques relief measures can increase
•Restlessness (e.g.relaxation,guided the release of endorphins
•Pupil dilation imagery,music therapy, and enhance the therapeutic
•Perspiration distraction, and massage) effects of pain relief
Assessment Nursing diagnosis Planning Intervention Rationale Evaluation
•Change in BP, HR, R before, after, and if medications.
from normal baseline possible during painful
data activities; before pain
occurs or increases: and
along with other pain relief
measures.
•Provide Mr.C.optimal pain Each client has a right to
relief with prescribed expect maximum pain relief.
analgesics. Optimal pain relief using
analgesics includes
determining the preferred
route drug, dosage,and
frequency for each
individual.
•Medicate before an
activity to increase Turning and ambulation
participation,but evaluate activities will be enhanced if
the hazard of sedation. pain is controlled or
tolerable. Assessing level of
sedarion should precede the
activity because many
analgesics cause sedation
•Evaluate the effectiveness and could compromise
of the pain control safety.
measures used through Research shows that the
ongoing assessment of most common reason for
Mr.C's pain experience. unrelieved pains failure to
routinely assess pain and
pain relief. Many clients
Analgesic Administration silently
•Check the medical order tolerate pain if not
Assessment Nursing diagnosis Planning Intervention Rationale Evaluation
for drug,dose,and specifically asked about it.
frequency of analgesic
prescribed. Ensures that the nurse has
•Determine analgesic the right drug right
selections (narcotic, route.right dosage right
nonnarcotic, or NSAID) client right frequency.
based on type and severity Various types of pain (e.g,
of pain. acute, chronic, neuropathic
arthritic) require different
analgesic approaches,Some
types of pain respond to
nonopioid drugs alone,while
•Institute safety others can be relieved by
precautions as appropriate combining a low-dose opioid
if Mr.C receives narcotic with a nonopioid.
analgesics. Side effects of opioid
•Instruct Mr.C.to request narcotics include drowsiness
prn pain medication before and sedation.
the pain is severe.
Severe pain is more difficult
to control and increases the
clients anxiety and fatigue.
The preventive approach to
•Evaluate the effectiveness pain management can
of analgesic at regular, reduce the total 24-hour
frequent intervals after analgesic dose.
each administration and The analgesic dose may not
especially after the initial be adequate to raise the
doses, also observing for client's pain threshold or
any signs and symptoms of may be causing intolerable or
untoward effects dangerous side effects
Assessment Nursing diagnosis Planning Intervention Rationale Evaluation
(e.g.,respiratory or both.Ongoing evaluation
depression, nausea and will assist in making
vomiting. dry mouth, and necessary adjustments for
constipation). effective pain management.
•Document Mr.C's
response to analgesics and
any untoward effects. Documentation facilitates
pain management by
communicating
effective and noneffective
pain management strategies
•Implement actions to to the entire health care
decrease untoward effects team.
of analgesics（e.g,
constipation and gastric Constipation is a common
irritation). side effect of opioid narcotics
and a treatment plan to
Simple Relaxation Therapy prevent occurrence should
•Consider Mr.C's be instituted at the
willingness and ability to beginning of analgesic
participate, preference, therapy.
past experiences, and
contraindications before
selecting a specific The client must feel
relaxation strategy. comfortable trying a
•Elicit behaviors that are different approach to pain
conditioned to produce management. To avoid
relaxation, such as deep ineffective strategies, the
breathing, yawning, client should be involved in
abdominal breathing, or the planning process.
peaceful imaging. Relaxation techniques help
 Assessment Nursing diagnosis Planning Intervention Rationale Evaluation
•Create a reduce skeletal muscle
quiet,nondisruptive tension,which will reduce the
environment with dim intensity of the pain.
lights and comfortable
temperature when
possible. Comfort and a quiet
atmosphere promote a
•Individualize the content relaxed feeling and permit
of the relaxation the client to focus on the
intervention (e.g.,by asking relaxation technique rather
for suggestions about what than external distraction.
Mr.C.enjoys or finds Each person may find
relaxing). different images or
•Demonstrate and practice approaches to relaxation
the relaxation technique more helpful than others.
with Mr.C.

Return demonstrations by
•Evaluate and document the participant provide an
his response to relaxation opportunity for the nurse to
therapy. evaluate the effectiveness of
teaching sessions.
Conveys to the health care
team effective strategies in
reducing or
eliminating pain.

NURSING CARE PLAN FOR INEFFECTIVE AIRWAY CLEARANCE

Nursing Data Nursing Diagnosis Planning Intervention Rationale Evaluation
Johti Singh is a 39- Physical Examination Ineffective airway Respiratory status: Cough Enhancement Outcome partially
year-old secretary Height:167.6 cm(5'6") clearance related to Airway patency as  Assist Ms.Singh to a Lying flat causes the met.Ms.Singh coughs
 Nursing Data Nursing Diagnosis Planning Intervention Rationale Evaluation
who was admitted Weight:54.4 kg(120 lb) thick sputum, evidenced by not sitting position with abdominal organs to shift and deep breathes
to the hospital with Temperature:39.4C(10 secondary to compromised head slightly flexed, toward the chest, crowding purposefully q1-2h
an elevated 3F) pneumonia, and  Fever is not shoulders relaxed,and the lungs and making it during the day. Her
temperature Pulse:68 BPM fatigue (as evidenced present knees flexed. more difficult to breathe. fluid intake is
fatigue, rapid, Respirations:24/ by rapid respirations,  Respiratory rate  Encourage her to take Deep breathing promotes approximately 1,500ml
labored minute nasal flaring and is in expected several deep breaths. oxygenation before each day. Cough
respirations; and Blood pressure: adventitious breath  Moves sputum controlled coughing. continues to be
mild dehydration. 118/70 mm Hg sounds) out of airway  Encourage her to take Controlled coughing is productive of
The nursing history Skin pale; cheeks  Is free of a deep breath,hold for accomplished by closure of moderately thick,
reveals that Ms. flushed; chills; nasal adventitious 2 seconds, and cough the glottis and the rusty-colored sputum.
Singh has had a bad flaring; use of with sound two or three times in explosive expulsion of air Inspiratory crackles
cold"for several accessory muscles; succession. from the lungs by the work remain present in right
weeks that just inspiratory crackles of abdominal and chest lower lobe. Her PaO2 is
wouldn't go away. with diminished breath muscles. 85mm Hg.
She has been sounds right base;  Encourage use of Breathing exercises help
dieting for several thick, yellow sputum incentive spirometry, maximize ventilation.
months and Diagnostic Data as appropriate.
skipping meals. Chest x-ray:right lobar  Promote systemic fluid Adequate fluid intake
Ms.Singh mentions infiltration hydration,as enhances liquefaction of
that in addition to WBC:14,000 appropriate. pulmonary secretions and
her full-time job as pH:7.49 facilitates expectoration of
a secretary she is PaCO2:33 mm Hg mucus.
attending college HCO3 :20 mEq/L Respiratory Monitoring
classes two PaO:80 mm Ha  Monitor rate, rhythm, Provides a basis for
evenings a week. depth, and effort of evaluating adequacy of
She has smoked one respirations. ventilation.
package of  Note chest Presence of nasal flaring
cigarettes per day movement,watching and use of accessory
since she was 18 for symmetry, use of muscles of respirations
years old. Chest x- accessory muscles, and may occur in response to
ray confirms supraciavicular and ineffective ventilation.
 Nursing Data Nursing Diagnosis Planning Intervention Rationale Evaluation
pneumonia. intercostal muscle
retractions.
 Auscultate breath As fluid and mucus
sounds,noting areas of accumulate, abnormal
decreased or absent breathe sounds can be
ventilation and heard including crackles
presence of and diminished breath
adventitious sounds. sounds owing to fluid-filled
air spaces and diminished
lung volume.
 Auscultate lung sounds Assists in evaluating
after treatments to prescribed treatments and
note results. client outcomes.
 Monitor client’s ability Respiratory tract infections
to cough effectively. alter the amount and
character of secretions. An
ineffective cough
compromises airway
clearance and
prevents mucus from being
expelled.
 Monitor client's People with pneumonia
respiratory secretions. commonly produce rust-
colored purulent
sputum.
 Institute respiratory A variety of respiratory
therapy therapy treatments may be
treatments(e.g.nebuliz used to open constricted
er)as needed. airways and liquefy
secretions.
 Monitor for increased These clinical
Nursing Data Nursing Diagnosis Planning Intervention Rationale Evaluation
restlessness, anxiety, manifestations would be
and air hunger. early indicators of hypoxia.
 Note changes in Evaluates the status of
SaO2,and tidal CO2and oxygenation,ventilation ,an
changes in arterial d acid-base balance.
blood gas values as
appropriate.
Oxygen Therapy
 Instruct Mu Singh Oxygen demand is greater
about importance of during febrile illness and
leaving oxygen delivery physical stress. At low Po2
device on. levels in the atmosphere,
oxygen saturation fall
rapidly,;therefore,oxygen
should be maintained,
especially during activity.

 Periodically check Too much or too little

oxygen delivery device oxygen con be detrimental,
to ensure that the especially in the
prescribed client with a history of
concentration is being smoking.
delivered.
 Observe for signs of In individuals with chronic
oxygen-induced lung disedse, the stimulus
hypoventilation. for breathing low oxygen
levels rather than elevated
carbon dioxide. This client
is at risk for COPD because
of smoking. Administration
of high level of oxygen
Nursing Data Nursing Diagnosis Planning Intervention Rationale Evaluation
could lead to
hypoventilation