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Assessment Nursing DX/Clinical Problem Client Goals/Desired Outcomes/Objectives Nursing Interventions/Actions/Orders and Rationale *I Evaluation Goals Interventions Subjective

Pt states that he cannot walk any farther than the bathroom or the chair without experiencing shortness of breath. Pt states that he was admitted because he was experiencing unusual shortness of breath

Objective Chart states chief complaint as shortness of air Diagnosis of congestive heart failure Pt demonstrates dyspnea upon exertion and acitivty. Problem Activity Intolerance

Long Term: Pt will demonstrate increased tolerance to activity by discharge.

*Evaluate medications the client is taking to see if they could be causing activity intolerance. Rationale: Medications such as beta-blockers, lipid- lowering agents, which can damage muscle, and some antihypertensives such as Clonedine and lowering the blood pressure to normal in the elderly can result in decreased functioning. (Ackley & Ladwig, 2008, p 121) *Assess nutritional needs associated with activity intolerance. Rationale: The decline in body mass, with physical weakness, inhibits mobility, increasing liability to deep vein thrombosis, and pressure ulcers. (Ackley & Ladwig, 2008, p 120) *Provide emotional support and encouragement to the client to gradually increase activity. Rationale: Fear of breathlessness, pain, or falling may decrease willingness to increase activity. (Ackley & Ladwig, 2008, p 120)

Goal met. Pt demonstrated increased tolerance to activity. Pt was able to ambulate to the room door and back to the bed without any abnormal changes in vitals. Pt stated that he felt stable after ambulating. Continue interventions as listed. Continue to evaluate the pts medications to see if they could be causing the activity intolerance. Continue to assess pts nutritional needs. Continue to provide emotional support and encouragement so that the pt may feel more confident about resuming activity. R/T Weakness and fatigue

Short Term:

Pt will participate in physical activity with appropriate changes in heart rate, blood pressure, and respirations within three days, by [date]. * Monitor vitals before and after any activity, noting any abnormal changes. Rationale: This can be caused by a temporary insufficiency of blood supply (Ackley & Ladwig, 2008, p 119) *Assess for pain before activity. Rationale: Pain restricts the client from achieving a maximal activity level and if often exacerbated by movement. (Ackley & Ladwig, 2008, p 120) *Obtain any necessary assistive devices or equipment needed before assisting in ambulation Rationale: Assistive devices can increase mobility by helping the client overcome limitations. (Ackley & Ladwig, 2008, p 120)

Goal met. Pt was able to participate in physical activity with appropriate vitals changes. His vitals were checked before and after activity and there were no indications of unstable vitals.

Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately. Post-operative nursing care for patients who underwent TAHBSO would include: 1. 2. 3. 4. 5. 6. Determines patients immediate response to surgical intervention. Monitor patients physiologic status. Assess patients pain level and administers appropriate pain relief measures. Maintains patients safety(airway, circulation, prevention of injury) Administer medication, fluid and blood component therapy, if prescribed. Assess patients readiness for transfer to in hospital unit or for discharge home based on institutional policy.

This post includes several nursing care plans for post-TAHBSO patients.

1 Acute Pain
Due to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammation, this damage will cause an inflammation of the nerves when the nerves are affected, there will be the presence of pain. Assessment Nursing Planning Nursing Diagnosis Interventions Establish rapport Subjective: Acute Short term: pain The patient secondary After 4 hours of Emphasize ordered diet to may nursing verbalized: surgical interventions, the Monitor vital signs operation patients pain scale will decrease Provide comfort My 10/10 to 5/10 incision is measure Encourage deep Rationale To gain trust To encourage patient not to eat untolerated food To obtain Evaluation Short term: The patients pain scale decreased 10/10 to 5/10 Long term:

hurts Objective: The patient manifested : -irritability -impaired physical mobility -disturbed sleep pattern -facial mask -diaphoresis restlessness -facial grimaces

The patients pain After 1 day of Provide safety measure To satisfy the diminished and nursing confinement of performed activities like interventions, patient Develop side patients pain will communication diminish and To inhibit pain movements and leg perform activities review bending like side procedures/expectations To prevent movement and leg and tell client when from injury bending treatment will hurt To alter pain Administer analgesics and diminish as indicated to maximal emotional dosage as needed stress Long term: breathing baseline data To reduce concern of unknown and associated muscle tension To maintain acceptable level of pain.

2 Hypothermia

Hypothermia is the sudden decrease of temperature. It is due to different factors such as exposure to cool environment, aging or medications. In a surgical procedure hypothermia occurs due to exposure to the cool environment in the OR. Anesthesia also affects body temperature. Inadequate clothing like the OR gown also contributes to heat loss. Assessment Nursing Planning Diagnosis S>O Hypothermia Short term: O> The patient may manifest: reduction in body temperature below normal range -shivering -cool skin -pallor -slow capillary refill -cyanotic nail beds After 3 hours of nursing interventions the patient will display core temperature within normal range Nursing Interventions > Establish rapport Rationale Evaluation

>To gain trust Short term: The patient displayed core temperature within normal range Long term:

The patient Long term: demonstrated behaviors to After 1 day of > Wrap in warm >Surface monitor and nursing blanket rewarming can promote interventions the normothermia lead to patient will > Avoid use of rewarming demonstrate heat clamps or shock due to behaviors to hot water bottles surface monitor and vasodilation promote >Administer normothermia medications to > To avoid prevent increasing in shivering temperature >Use hyperthermia > To warm

>To obtain > Monitor vital baseline data signs > These > Remove wet measures clothing and protect patient prevent pooling from heat loss of antiseptic solutions under > To promote client in OR heat

hypertension -tachycardia

blanket >Administer fluids during rewarming > Keep client quiet

patient > To prevent hypovolemic shock

>To reduce potential for fibrillation in > Provide well- cold heart balance high calorie diet > To replenish glycogen stores and > Perform range-of-motion nutritional balance exercises, provide support hose, reposition, > To reduce do cough/deep circulatory breathing stasis exercises, avoid restrictive > impaired clothing circulation can result in severe > Protect skin by tissue damage repositioning, applying lotion > To provide and avoid direct heat contact with heating appliance or blanket

> Provide patent airway with humidified oxygen when used

3 Hyperthermia
Organisms releases endotoxin which stimulates the release of pyrogens from the leukocytes resetting the bodys internal thermostat to febrile level then there will be activation of hypothalamus which will result to an increase in epinephrine and heparin, vasoconstriction of cutaneous vessels. Then heat will be produce as peripheral vasodilation results in skin flushing and skin which is warm to touch. Assessment Nursing Planning Nursing Diagnosis Interventions Hyperthermia Short term: > Establish S> The rapport patient may After 4 hours of manifest: nursing > Monitor vital interventions the signs -headache patient will maintain core > Monitor body temperature O> The temperature within normal every 4 hours or patient range more often if may indicated manifest: Long term: -increase in > Loosen body After 1 day of patients temperature nursing clothing above interventions the normal patient will be free and remove from Rationale Evaluation

>To gain trust Short term: >To obtain baseline data The patient maintained core > To evaluate temperature effectiveness within normal range of interventions Long term: >To promote heat loss The patient through was free from radiation and complications conduction such as irreversible >To promote brain damage and acute renal heat loss

range -flushed skin, warm to touch tachycardia -seizures or convulsions

complications such as irreversible brain damage and acute renal failure

blankets

through evaporation

failure

> Apply ice bags to axilla or groin >To reduce and do TSB fever > Administer antipyretic as ordered > Observe patient for confusion or disorientation > Determine patients preference for liquids > Changes LOC may result from tissue hypoxia >Offering patient liquids he prefers promotes adequate hydration

> To allow patient easy > Keep liquids at access bedside and within reach > To identify changes and > Monitor intake progress of the treatment and output accurately >These > Administer I.V measure fluid as ordered prevents excessive loss > Give patient of water, sodium

oresol >Provide supplement oxygen

chloride and potassium > To replace loss fluid and electrolytes

> Maintain bed rest > To offset increase > Provide high- oxygen caloric diet, tube demands and consumption feedings or parenteral nutrition > To reduce metabolic demands > To meet increased metabolic demands

4 Anxiety
Due to upcoming surgical procedure patients are usually experiencing anxiety. The brain signals our body part to initiate responses such as fatigue, nausea and abdominal pain. Assessment Nursing Planning Diagnosis Anxiety Short term: S> The related to patient situational After 3 hours of may Nursing Interventions > Establish rapport Rationale Evaluation

>To gain trust Short term: >To obtain The patient

manifest: - concerns due to change in life event - fear - nausea - abdominal pain - fatigue - sleep disturbance - urinary hesitancy O> The patient may manifest: - poor eye contact extraneous

crisis

nursing interventions the > Monitor vital patient will signs verbalized awareness of >Listen feelings of anxiety attentively; allow patient to Long term: express feelings verbally After 1 day of nursing >Identify and interventions the reduce as many patient will appear environment relaxed and report stressors anxiety is reduced to a manageable >Provide level accurate information about the situation > Provide comfort measures like back rub and soft music

baseline data >To allow patient to identify anxious behaviors and discover source of anxiety

verbalized awareness of feelings of anxiety Long term:

The patient appeared relaxed and reported that > Anxiety anxiety was commonly reduced to a results from manageable lack of trust in level the environment >Helps the patient what is reality based >To decrease autonomic response to anxiety

>Use cognitive >To correct faulty therapy catastrophic >Refer patient to interpretations of physical professional mental health

movement restlessness - irritability - anorexia - insomnia - impaired attention Trembling, hand tremors

resources

symptoms >To provide ongoing mental health assistance

5 Fatigue
Due to poor physical condition after surgical procedure, body insist demands of nutrition and oxygen that results to fatigue Assessment Nursing Planning Diagnosis S>O Fatigue Short term: related to physical After 4 hours of O> the condition nursing patient manifested: intervention, the patient will demonstrate an -Pale skin increase energy Nursing Interventions >Establish rapport >Monitor vital signs >Evaluate the need for Rationale Evaluation

>To gain trust Short term: >To obtain maintenance data The patient demonstrated increase energy output without >To determine presence of degree of

-Impaired physical mobility -Irritability -Weakness -Pain= 5/10 -Activity intolerance -stress

output with presence of fatigue Long term: After 3 day of nursing intervention, the patient will perform activities of daily living and participate in desired activities at level of ability

individual fatigue fatigue assistance and discuss lifestyle >Enhance Long term: changes imposed commitment in by fatigue state promoting The patient optimal performed >Establish outcomes activities of realistic activity daily living goals with client >To indicate and participate the need to in desired >Instruct client alter activity activities at in ways to level level of monitor activities responses to activity and significant signs and symptoms

6 Sexual Dysfunction
Dysfunction of the female reproductive system can produce depression and even anxiety. The patient experiences this due to deficient knowledge about the dysfunction and the decrease in sexual desire. Assessment Nursing Planning Diagnosis S > The Sexual Short term: patient may Dysfunction verbalized: related to After 4 hours of altered nursing body -problem interventions the such as loss structure patient will of sexual and identify stressors Nursing Interventions >Establish rapport >Monitor vital signs Rationale Evaluation

>To gain trust Short term: >To obtain maintenance data

The patient identified stressors in lifestyle that > Obtain sexual >To maximize contributes to

desire - inability to achieved desired satisfaction -conflicts involving values O> the patient manifested: -alteration in relationship with SO -Change of interest in self and others

function

in lifestyle that history including communication the dysfunction may contribute to usual patterns of and the dysfunction functioning and understanding Long term: level of desires >Sexual Long term: The patient > Be alert to concerns are verbalized comments of often disguised understanding After 3 day of client as humor, nursing of individual sarcasm, or interventions the reasons for offhand patients will > identify sexual verbalize current stressors remarks problems understanding of in individual individual reasons situations > These factors for sexual may be problems > Avoid making producing value judgments enough anxiety to cause depression >Establish therapeutic > They do not nurse-client help the client relationship >Provide ways >To promote to obtain privacy treatment and facilitate sharing of sensitive information >To allow sexual expression for individual

between partners without embarrassment

7 Risk for Infection


The skin considered as the first line of defense against any foreign organism when surgical procedure impaired the skin, possible entry of microorganism therefore may cause infection Assessment Nursing Planning Diagnosis S> O Risk for Short term: infection secondary After 4 hours of O> the to patient nursing manifested: surgical interventions, the incision patient shall identify and -Weakness demonstrate intervention to -Pallor prevent infection -with dry Long term: and intact dressing on After 1 day of the area. nursing interventions, the -Pain over patient will not the incision have infection -Irritability Nursing Interventions >Establish rapport >Monitor V.S. Rationale Evaluation

>To gain trust Short term: >To obtain baseline data The patient identified and demonstrated interventions to prevent risk of infection Long term:

>Note signs and >To reduce symptoms of complication sepsis and monitor for infection >Provide wound healing such as >To reduce cleaning of risk for wound infection

The patient doesnt experience >Provide care, >To promote infection change dressing healing to the as needed incision >Encourage increase intake >To prevent infection to

-Presence of intact dressing -Impaired physical mobility -diaphoresis -fever -seizures

of Vitamin C >Encourage deep breathing exercise

increase immune resistance >To increase healing of wound

8 Risk for Deficient Fluid Volume


Decrease intravascular, interstitial, or intracellular fluid refers to dehydration. Fluid volume deficit or hypovolemia occurs from a loss of body fluid or the shift of fluids into the third space or reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria and increased perspiration. It also occurs to patient who undergone surgery. In an operation the patient is losing too much body fluid through blood loss that can lead to deficient fluid.

Decrease intravascular, interstitial, or intracellular fluid refers to dehydration. Fluid volume deficit or hypovolemia occurs from a loss of body fluid or the shift of fluids into the third space or reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria and increased perspiration. It also occurs to patient who undergone surgery. In an operation the patient is losing too much body fluid through blood loss that can lead to deficient fluid. Assessment Nursing Planning Diagnosis S > The Risk for Short term: patient may fluid Nursing Interventions >Establish rapport Rationale Evaluation

>To gain trust Short term:

manifest: - thirst -weakness O> the patient manifested: -decrease urine output -sudden weight loss -decrease skin turgor -dry mucous membranes - sunken eyeballs -change in mental state

volume deficit

After 4 hours of nursing interventions the patient will identify risk factors and appropriate interventions Long term: After 3 day of nursing interventions the patients will demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit

>Monitor vital signs > Encourage increase oral fluid intake

>To obtain maintenance data > To replace loss fluids

The patient identified risk factors and appropriate interventions Long term:

> Provide >Prevents supplemental peak in fluid fluids as ordered level

The patient demonstrated behaviors or lifestyle > Monitor intake >To ensure changes to and output accurate picture of fluid prevent development of > Provide safety status fluid volume measures > Confusion deficit > Encourage the can lead to accidents use of oresol >To replace loss electrolyte.