VIII.

NCP Proper
Explanation of the problem Px#1: Abdominal LTO > Within 2 days Abdominal pain is pain due to UTI and of nursing associated with 4 LBM interventions, the clinical features that client will verbalize may vary with the S > Nagkaroon sense of comfort or degree of siya ng stomach contentment. obstruction and its trouble at umatake > Within 2 days of location: vomiting, rin ang UTI niya nursing interventions, abdominal pero OK na siya. Di the client will distension, pain and na sumasakit ang demonstrate obstipation. tiyan niya. As behaviours of optimal Vomiting is the verbalized by the level of ease. response to the grandmother obstruction in the > wala na pong STO > after 3 hours of upper GI tract. The masakit sa akin, nursing intervention, consequences of tapos po hindi na the client will be able persistent vomiting po masakit pag to participate in are as would be umiihi ako. As desirable and realistic expected: fluid loss verbalized by the health-seeking leading to patient behaviours. dehydration, > after 8 hrs of nursing electrolyte O > Seen happy intervention, the client imbalance as and lively at all will be able to: needed ions are lost times a) enumerate the in the vomitus, and > patient doesnt relaxation the loss of nutrients. express grimacing techniques When obstruction when moving b) apply deep occurs in the lower > talkative and breathing GIT, vomiting is most of the time exercises less able to clear Problem Goals Interventions Dx > Determine the type of comfort client is experiencing. > use pain assessment scale to identify intensity of pain > Verify that client is managing pain and pain components effectively. Tx > establish context in which comfort is realized. > assist client to use and modify medication regimen > provide ageappropriate comfort measures like back rub, change of position Edx > encourage Rationale > provides baseline for assessing changes in pain level and evaluating interventions. > provides baseline for assessing changes in pain level and evaluating interventions. > provides baseline for assessing changes in pain level and evaluating interventions. > to provide knowledge regarding the clients condition > to make best use of pharmacologic pain management. > to provide nonpharmacological pain management. Criteria for Evaluation Goal met if the client will be able to demonstrates feeling of wellness and fully overcome his illness. Goal partially met if the client will be able to do one or two objectives within 8 hours. Goal not met if the client will not be able to do any of these activities. Evaluation

> to prevent fatigue

laughing with family > doesnt express irritability and sensitiveness to noise A > Readiness for enhanced comfort related to presence of support system and effective treatment.

c) enumerate the importance of doing DBE

backed-up lumen contents. Its consequence is intestinal distention as parts of the GIT proximal obstruction dilate to accommodate the increase in volume. The pain can be quite severe, with peak intensity associated with waves of peristaltic contraction.

adequate rest periods > encourage verbalization of feelings and make time for listening or interacting. > Encourage ageappropriate diversional activities.

> to lessen the burden that the client is feeling

> to divert the thoughts of the patient from his illness

Reference: 3rd Edition, Pathophysiology Concepts and Applications for Health Care Professionals Thomas J. Nowak and A. Gordon Handford