XIIII.

NURSING PROCESS

Problem#1: Acute pain Subjective Data: patient verbalize sumasakit ang sugat ko pag nauubo o tumatawa ako. Pain scale of 7/10. Objective Data: Facial grimacing Nursing Diagnosis: Acute pain related to post operation incision site Struvite stones are usually large (staghorn calculi) and result from infection. These stones need to be treated surgically and the entire stone removed, including small fragments, as otherwise these residual fragments act as a reservoir for infection and recurrent stone formation.(Weerakkody&Jones) NOC: Pain Control NIC: Pain management Short term Goal: After 3 hours of nursing intervention, patient will be able to learn the significance of deep breathing exercise. Long term Goal: after 8 hours of nursing intervention, patient pain scale will decrease from 7/10 to 4/10. Interventions:

1. Assess pain characteristic (quality, location, intensity; pain scale and duration of pain). Assessment of pain experienceis the first step in planning pain management strategies (Gulanick and Myers, 2011). 2. Assess vital signs, noting tachycardia, hypertension and increase respiration. Changes in vital signs often indicate acute pain and discomfort (Doenges et al 2006) 3. Provide comfort measure such as providing back rub and restful environment. Promotes relaxation, reduces muscle tension and may reduce reflex spasms (Doenges et al 2006). 4. Teach and encourage use of deep breathing exercises. Relieve muscle and emotional tension; enhances sense of control and may improve coping abilities(Doenges et al 2006). 5. Assist client to a comfortable position. May relieve pain and enhance circulation (Doenges et al 2006).

Problem#2: Risk for infection Objective data: fresh incision site Nursing Diagnosis: Risk for Infection related to Fresh Incision Site Infection occur when an organism (bacterium, virus, fungus of other parasite) invades susceptible host. Breaks in the integument, the bodys first line of defense, and/or the mucous membranes allow invasion of the pathogens. If the persons immune system cannot combat the invading organism adequately, an infection occurs. Open wounds, traumatic or surgical, can be sites for infection (Gulanick and Myers,2011) NOC: Infection Control

NIC: Infection Protection Short-term Goal: After 1 hour of nursing intervention, patient will be able to understand and verbalize the importance of hand-washing. Long-term Goal: After 8 hours of nursing intervention, patient will be free from infection as evidence by normal vital signs and absence of purulent drainage from incision site. Interventions: 1. Assess vital signs especially temperature. Temperature greater than 37.7 celcius suggests infection; fever spikes that occur and subside are indicative of wound infection (Gulanick and Myers, 2011). 2. Assess for the signs of infection such as redness, swelling; increased pain; purulent drainage from incision, and injury. Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified in the culture (Gulanick and Myers, 2011) 3. Teach patient the importance of handwashing. Knowing the importance of washing hands will help in avoiding infectious diseases (Gulanick and Myers, 2011). 4. Assess for exposure to individuals with active infections. This information provides warning for potential infection (Gulanick and Myers, 2011). 5. Maintain and teach aseptic technique for dressing changes and wound care. Use of aseptic technique decreases the chances of transmitting or spreading pathogens to the patient (Gulanick and Myers, 2011). 6. Wash hands before contact with patients and between procedures with the patient. Friction and running water effectively remove microorganisms from hand. Washing

before the procedure reduces the risk of transmitting pathogens from one area of the body to another (Gulanick and Myers, 2011). Evaluation: Short-term Goal: Goal met. After 1 hour of nursing intervention, patient understands and verbalized the importance of hand-washing. Long-term Goal: Goal met. After 8 hours of nursing intervention, patient was free from infection as evidenced by normal vital signs and absence of purulent drainage from incision site. Problem#3: Knowledge deficit Subjective data: Patient verbalized, hindi ko alam na ang paninigarilyo ay isa sa pwedeng dahilan ng sakit na to. Objective data: smoking of 1 pack a day Nursing Diagnosis: Deficient knowledge related to Hazards of Smoking Knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. Many factors influence patient education, including age, cognitive level, developmental stage, and physical limitations. Older patients needs more time for teaching and may have sensory-perceptual deficits and cognitive changes that may require modification in teaching techniques (Doenges et al 2006). NOC: Knowledge; Disease Process NIC: Teaching; Disease Process

Short-term Goal: After 30 minutes of health teaching, patient will be able to express understanding the harms that smoking can do to the body. Long-term Goal: After 1 hour of nursing intervention, patient will be able to express willingness to stop smoking as evidence by patient verbalization. Intervention: 1. Evaluation: Short-term Goal: Goal met. After 30 minutes of health teaching, patient was able to express understanding the harms that smoking can do to the body. Long-term Goal: Goal met. After 1 hour of nursing intervention, patient was able to express willingness to stop smoking as evidenced by patient verbalization.

Problem#4: Activity intolerance Subjective data: Hindi na ako mkagalaw ng maayos dahil sumasakit yung sugat ko. as verbalized by the patient. Objective data: pain scale of 7/10 when moving, facial grimacing Nursing Diagnosis: Activity Intolerance related to Pain secondary to Post-Surgical Incision Site. Activity intolerance may be related to factors such as obesity, aging, malnourishment, anemia, pain, medication or emotional stress (Doenges et al 2006).

NOC: Selfcare: Activities of Daily Living NIC: Energy Management Short-term Goal: After 30 minutes of health teaching, patient will be able to express willingness to do ADLs. Long-term Goal: After 5 hours of nursing intervention, patient will be able to do simple ADLs that is within her capacity. Intervention: 1. Assess the patient level of mobility. This information will serve as a basis for formulating realistic short-term and long-term goals (Doenges et al 2006). 2. Teach and encourage use of deep breathing exercises. Relieve muscle and emotional tension; enhances sense of control and may improve coping abilities(Doenges et al 2006). 3. Teach ROM and strengthening exercises. Exercise promotes increased venous return, prevents contractures, and maintains muscle strength and endurance (Doenges et al 2006). 4. Assist with ADLs as indicated; however, avoid doing for patients what they can do for themselves. Assisting the patient with ADLs allows for putting not much effort of the patient thus conserving energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patients activity tolerance and self-esteem (Doenges et al 2006). 5. Progress activity gradually, as with the following: active range of motion exercise in bed, progressing to sitting and standing, deep breathing exercises three or more times daily,

walking in room 1 to 2 minutes three times daily. Appropriate progression prevents overexerting the patient while promoting activity (Doenges et al 2006). Evaluation: Short-term Goal: Goal met. After 30 minutes of health teaching, patient was able to express willingness to do ADLs. Long-term Goal: Goal met. After 5 hours of nursing intervention, patient was able to do simple ADLs that is within her capacity.

Problem#5: disturbed sleeping pattern Subjective data: Hindi nga ako makatulog ng maayos dahil sumasakit yung sugat ko kapag gumagalaw ako. as verbalized by the patient. Objective data: Pain scale of 7/10 when moving. Nursing Diagnosis: Disturbed Sleeping Pattern related to Pain secondary to Post-Surgical Incision site. Sleep is required to provide energy for physical and mental activities. the amount of sleep that individuals requires varies with age and personal characteristic. Older patient sleep less during the night but may take more naps during the day to feel rested. Disruption in the individuals usual diurnal pattern of sleep and wakefulness may be temporary or chronic. Sleep pattern can be affected by pain, depression,aging and environment, especially in hospital care unit (Gulanick and Myers, 2011).

NOC: Sleep NIC: Sleep Enhancement Short-term Goal: After 3 hours of nursing intervention, patient will be able to rest and relax as evidence by verbalization of feeling rested. Long-term Goal: After 8 hours of nursing intervention, patient will be able to achieved optimal amounts of sleep as evidenced by rested appearance. Intervention: 1. Assess the patients perception of cause of sleep difficulty and possible relief measures to facilitate treatment. Patients may have insight into the etiological factors of the problem. Knowing the specific etiological factor will guide appropriate therapy (Gulanick and Myers, 2011). 2. Assist client to a comfortable position. May relieve pain and enhance circulation (Doenges et al 2006). 3. Provide an environment conducive to sleep or rest. Facilitating good environment, can enhance relaxation and sleeping (Doenges et al 2006). 4. Instruct the patient to avoid heavy meals, alcohol, caffeine, or smoking before retiring. Although hunger can also keep one awake, gastric digestion and stimulation from caffeine and nicotine can disturb sleep (Doenges et al 2006).. 5. Eliminate nonessential nursing activities. This approach promotes minimal interruption in sleep or rest (Doenges et al 2006). Evaluation:

Short-term Goal: Goal met. After 3 hours of nursing intervention, patient was able to rest and relax as evidenced by verbalization of feeling rested. Long-term Goal: Goal met. After 8 hours of nursing intervention, patient was able to achieved optimal amounts of sleep as evidenced by rested appearance.