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Nursing process
NURSING PROCESS
“ A Systematic method of providing
  Nursing care”
• It provides a framework for planning
  and implementing Nursing care.
• This involves a problem-solving
  approach that enables the nurse to
  identify patient problems and potential
  at-risk needs (problems) and to plan,
  deliver, and evaluate nursing care in an
  orderly, scientific manner.
Components of nursing process:
The nursing process consists of five dynamic
   and interrelated phases:
1.   assessment
2.   diagnosis
3.   planning
4.   implementation
5.   evaluation.
How the nursing process applies to the
              scientific method
Scientific method              Nursing process

State an observed problem      Assessment

Form a hypothesis about the    Nursing diagnosis
problem

Develop a method to test the   Outcome Identification and
hypothesis                     Planning

Collect the data               Implementation
Analyze the data

Draw conclusions about the     Evaluation
hypothesis
                                                       4
Assessment
Assessment involves the systemic collection of
   Patient data.(collect data, validate data,
   organize data, document data)
Data Collection
 ( subjective &objective data)
• Nursing history( Biographic data, current
   physical &emotional complaints, past medical
   history, past and current ability to perform
   ADL’S, socio-economic factors)
• Physical Assessment.
• Review of lab &Diagnostic test results.
• Review other available Health Information.
Validation of data
The information gathered during the assessment
  phase must be complete, factual, and accurate
  Because the nursing diagnosis interventions are
  based on this information.
Validation is the act of "double-checking“ or
  verifying data to confirm that it is accurate
      and factual.
Organization of data
The nurse uses a written or computerized format
  that organizes the assessment data
  systematically. The format may be modified
  according to the client's physical status.
Documenting data:
To complete the assessment phase, the nurse
records client's data.
Accurate documentation is essential and should
include all data collected about the client's
health status. Data are recorded in a factual
manner and not interpreted by the nurse.
           E.g.: the nurse record the client's
breakfast intake as" coffee 240 ml. Juice 120 ml, 1
egg". Rather than as "appetite good".
PURPOSE OF ASSESSMENT:
•   To validate a diagnosis
•   To provide basis for effective nursing
    care.
•   It helps in effective decision making
•   Basis for accurate diagnosis
•   It promote holistic nursing care
•   To provide effective and innovative
    nursing care
•   To collecting data for nursing research
•   To evaluation of nursing care
TYPES OF ASSESSMENT
Type                    Aim                                Time frame

1- Initial assessment   Initial identification of normal   Within the specified time
                        function, functional status, and   frame after admission to a
                        collection of data concerning      hospital, nursing home,
                        actual or potential dysfunction.   ambulatory healthcare center.
                        Baseline for reference and
                        future comparison.


2- Focus assessment     Status determination of a          Ongoing process, integrated
                        specific problem identified        with nursing care, a few
                        during previous assessment.        minutes to a few hours
                                                           between assessments.
                        Comparison of client’s current     Several months (3,6,9 months
3- Time – lapsed        status to baseline obtained        or more) between assessment
reassessment            previously, detection of
                        changes in all functional health
                        patterns after an extended
                        period of time has passed


                        Identification of life –           AT anytime
4- Emergency            threatening situation
assessment
NURSING DIAGNOSIS
Nursing diagnosis is a clinical judgment about
  individual, family, or community responses to
  actual or potential health problems/life processes.
  Nursing diagnoses provide the basis for selection of
  nursing interventions to achieve outcomes for
  which the nurse is accountable (NANDA, 1997).
Steps:
Each Nursing Diagnosis has three components:
*Label an actual or potential health problems that
  Nursing care can affect.
*Related factors- Factors that may precede,
  contribute to or be associated with the human
  response.
*Evidence – Signs symptoms that point to the Nursing
  Diagnosis.
TYPES OF NURSING DIAGNOSIS
• Actual Diagnosis: An actual diagnosis is a
   statement about a health problem that the
   client has, and could benefit from nursing care.
   An example of an actual nursing diagnosis is:
---Ineffective airway clearance related to
   decreased energy and manifested by an
   ineffective cough.
• A risk diagnosis is a statement about a health
   problem that the client doesn't have yet, but is
   at a higher than normal risk of developing in the
   near future. An example of a risk diagnosis is:
---Risk for injury related to altered mobility and
   disorientation.
While walking Mrs. Lin to the bathroom, she
  complains of dizziness:
• Ask her if the dizziness is related to an activity
• Take her blood pressure in lying and standing
  positions
• Determine what interventions will reduce her
  dizziness
• Later, in the day, check with her if additional
  episodes have occurred
• Teach her to change her position slowly
• Formulate the nursing diagnosis “High Risk for
  Injury related to vertigo secondary to postural
  hypotension”
• A complete nursing diagnosis is written in
  the format problem related to cause of
  problem as evidenced by symptoms of
  problem

• An example of such a nursing diagnosis
  would be Impaired gas exchange related to
  excessive secretions as evidenced by O2
  saturation of 86%.
Nursing process
NURSING PLANNING
The third step of the nursing process; includes
 the formulation of guidelines that establish
 the proposed course of nursing action in the
 resolution of nursing diagnoses and the
 development of the client’s plan of care.

The planning of nursing care occurs in three
  phases:
(initial, ongoing, and discharge.)
Each type of planning contributes to the
  coordination of the client’s comprehensive
  plan of care.
The four critical elements of planning
1.Establishing priorities.
In establishing priorities,
   the nurse examines the
   client’s nursing
   diagnoses and ranks
   them in order of
   physiological or
   psychological
   importance.

One of the most common
  methods of selecting
  priorities is the
  consideration of Maslow’s
  hierarchy of needs, which
  requires that a life-
  threatening diagnosis be
  given more urgency than a
  non life threatening
  diagnosis.
Nursing process
2.Setting goals and developing expected
                     outcomes
A goal is a specific and measurable objective
  designed to reflect the patient highest level
  of wellness and independence in function.
There are 2 categories in goals.
• Short term – Can be met fairly and quickly
  (hours or days)
• Long term – cover a long time span
e.g.
The patient will be free of infection throughout
  hospitalization.
3. Developing Expected outcomes
Expected outcome define when a patient
  goal has been met and assist in evaluating
  the extent to which the Nursing diagnosis
  has been resolved.
e.g.
Goal : The patient lung will remain clear post
  operatively .
Expected outcomes:
- The sputum will remain white
- The patient will remain afebrile
- The lungs will be clear to auscultation
Nursing process
4.Planning nursing interventions (with
 collaboration and consultation as needed)
Nursing interventions are treatment, based
  upon clinical judgment and knowledge that a
  nurse performs to enhance patient / client
  outcomes.
Dependent – a nursing action based on the
  instruction of another professional.
Independent – requires no supervision.
Interdependent – actions carried out by the
  nurse in collaboration with another health
  care professional.
• Nursing interventions must be specifically
  designed to meet the identified goal.
• Each intervention should be supported by a
  scientific rationale.
Nursing process
IMPLEMENTATION
While implementing nursing orders, the
  nurse continues to reassess the client at
  every contact, gathering data about the
  client’s responses to nursing activities and
  about any new problems that may develop.
To implement the care plan successfully,
  nurses need cognitive, interpersonal, and
  technical skills. These skills are distinct
  from one another.
The cognitive skills (intellectual skills) include
  problem solving, decision making, critical
  thinking, and creativity.
When implementing interventions, nurses should follow
  these guidelines:
• Base nursing interventions on scientific knowledge,
  nursing research, and professional standards of care
  whenever possible.
• Clearly understand the order to be implemented and
  question any that are not understood.
• Adapt activities to the individual client, a client’s beliefs,
  values; age, health status, and environment are factors
  that can affect the success of a nursing action.
• Implement safe care
• Provide teaching, support and comfort to enhance the
  effectiveness of nursing care plans.
• Be holistic; view the client as a whole.
• Respect the dignity of the client and enhance the client’s
  self- esteem
• Encourage client to participate actively in implementing
  the nursing interventions.
Documenting Nursing Activities,
• the nurse complete the implementing phase
  by recording the interventions and client
  responses in the nursing process notes.

• The nurse may record routine or recurring
  activities such as mouth care in the client
  record at the end of shift, while some
  actions recorded in special worksheets
  according to agency policy.

• Immediate recording helps safeguard the
  client to prevent double actions.
EVALUATION
• The last phase of the nursing process, follows
  implementation of the plan of care, it’s the
  judgment of the effectiveness of nursing care to
  meet client goals based on the client’s behavioral
  responses.
When determining whether a goal has been achieved,
  the nurse can draw one of the three possible
  conclusions:
   – The goal was met, that is the client response is
     the same as the desired outcomes.
   – The goal was partially met, that is either a short
     term goal was achieved but the long term was
     not, or the desired outcome was only partially
     attained.
   – The goal was not met.
“When goals have been partially met or when
 goals have not been met, two conclusions
 may be drawn:
    • The care plan may need to be revised,
      since the problem is only partially
      resolved
OR
    • The care plan does not need revision,
      because the client merely needs more
      time to achieve the previously
      established goals.
    • So the nurse must reassess why the
      goals are not being partially achieved.
APPENDECTOMY
Client assessment database:
Activity & rest: May report     Malaise
Circulation: may exhibit        Tachycardia

Elimination: May report         Constipation of recent onset of diarrhea
                                Abdominal distension, tenderness/
                                rebound tenderness, rigidity, decreased
May exhibit                     or absent bowel sound .

Food/fluid : may report         Anorexia , nausea , Vomiting

Pain/ Discomfort : May report   Abdominal pain around the epigastrium
                                and umbilicus, which may have an
                                insidious onset and become
                                increasingly severe (RLQ) at mc Burney’s
                                point.


Respiration: May exhibit        Tachypnea, Shallow respirations
Diagnostic studies:
• CBC: WBC s are often elevated,
  neutrophil count elevated
• Abdominal CT, USG, Abdominal
  radiographs.
Nursing Priorities:
• Prevent complication
• Promote comfort
• Provide information about surgical
  procedure/prognosis, treatment needs, and
  potential complications.
Discharge Goals:
• Complication prevented / minimized
• Pain alleviated/controlled
• Surgical procedure/ prognosis , treatment
  understood.
Nursing Diagnosis: Risk For infection
Outcome criteria: wound healing
Actions/ Interventions                  Rationale
Independent
Practice / instruct in good hand        Reduces the risk of spread of bacteria
washing and aseptic wound care.
Encourage and provide perineal care
Inspect Incision and dressings. Note    Provides for early detection of
characteristics of drainage from        developing infectious process.
wound/drains, presence of erythema
Monitor vital signs . Note if fever,    Suggestive of presence of infection/
chills diaphoresis, changes in          developing sepsis, abscess, peritonitis
mentation , report if increase
abdominal pain.
Collaborative
Administer antibiotic as appropriate    Antibiotics given before
                                        appendectomy primarily for
                                        prophylaxis of wound infection and
                                        continued post operatively
Nursing Diagnosis: Risk For deficient fluid volume
Outcome criteria: hydration(Maintain adequate fluid balance as evidenced by
  moist mucous membrane, good skin turgor, stable vital signs, adequate
  urine output.
Action/Intervention                      Rationale
Independent

Monitor Vital signs                      Variations help identify intra vascular
                                         volume.
Inspect mucous membrane ; assess skin    Indicators adequacy of peripheral
turgor and capillary refill.             circulation and cellular hydration.

Monitor I&O; note urine color            Decreasing output concentrated urine
concentration, specific gravity.         with increasing specific gravity suggests
                                         dehydration.

Auscultate bowel sounds. Note passing    Indicators return of peristalsis , readiness
flatus , bowel movement                  to begin oral intake
Provide clear liquids in small amounts   Reduces the risk of gastric irritation/
,when oral resumed                       vomiting and fluid loss
Give frequent mouth care with special    Dehydration results in drying & painful
care to protect lips                     cracking of lips and mouth
Collaborative
Maintain gastric / intestinal suction as   To decompress the bowel, promote
indicated                                  intestinal rest, and prevent vomiting
Administer IV fluids and electrolytes      The peritoneum reacts to irritation/
                                           infection by producing large amount of
                                           intestinal fluid , possibly reducing
                                           circulating blood volume, resulting in
                                           dehydration and relative electrolyte
                                           imbalances.
Nursing Diagnosis: Acute pain related to inflammation / presence of surgical
incision.
Outcome criteria: report pain relieved / minimized
Actions/ interventions                      Rationale
Pain management
Independent
Assess pain, noting location,              Use full in monitoring effectiveness of
characteristics, severity (0-10 scale)     medication, progression of healing.
                                           Changes in characteristics of pain may
                                           indicate developing abscess/peritonitis
                                           require medical evaluation and
                                           interventions
Provide accurate , honest information    Being informed about progress of
to client                                situation provides emotional support,
                                         helping to decrease anxiety


Keep at rest in semi fowler's position   Relieving abdominal tension, which is
                                         accentuated by supine position.

Encourage early ambulation               Promotes normalization of organ
                                         function

Provide diversional activities.          Refocuses attention , promotes
                                         relaxation.

Collaborative

Keep NPO/Maintain NG suction initially   Decreases the discomfort of early
                                         intestinal peristalsis and gastric
                                         irritation/vomiting


Administer analgesics as indicated       Relief of pain facilitates cooperation
                                         with other therapeutic interventions
                                         e.g. ambulation , pulmonary toilet.
Nursing Diagnosis: Deficient Knowledge ( regarding condition, prognosis,
treatment, self care, and discharge needs.)
Outcome criteria: Verbalization of understandings
Independent
Teaching disease process

Identify symptoms requiring medical           Prompt interventions reduces risk of
evaluation e.g. increasing pain, edema/       serious complications e.g. delayed
erythema around wound , presence of           wound healing, peritonitis
drainage, fever


Review post operative activity                Provides information client to plan for
restrictions, e.g. heavy lifting, exercise,   return usual routines.
sports, driving

Encourage progressive activities as           Prevent fatigue, promotes healing and
tolerated with periodic rest periods          well being

Discuss the care of incision , including      Understanding promotes cooperation
dressing changes, bathing restrictions,       with therapeutic regimen, enhancing
and return to physician.                      healing and recovery process.
Nursing process

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Nursing process

  • 2. NURSING PROCESS “ A Systematic method of providing Nursing care” • It provides a framework for planning and implementing Nursing care. • This involves a problem-solving approach that enables the nurse to identify patient problems and potential at-risk needs (problems) and to plan, deliver, and evaluate nursing care in an orderly, scientific manner.
  • 3. Components of nursing process: The nursing process consists of five dynamic and interrelated phases: 1. assessment 2. diagnosis 3. planning 4. implementation 5. evaluation.
  • 4. How the nursing process applies to the scientific method Scientific method Nursing process State an observed problem Assessment Form a hypothesis about the Nursing diagnosis problem Develop a method to test the Outcome Identification and hypothesis Planning Collect the data Implementation Analyze the data Draw conclusions about the Evaluation hypothesis 4
  • 5. Assessment Assessment involves the systemic collection of Patient data.(collect data, validate data, organize data, document data) Data Collection ( subjective &objective data) • Nursing history( Biographic data, current physical &emotional complaints, past medical history, past and current ability to perform ADL’S, socio-economic factors) • Physical Assessment. • Review of lab &Diagnostic test results. • Review other available Health Information.
  • 6. Validation of data The information gathered during the assessment phase must be complete, factual, and accurate Because the nursing diagnosis interventions are based on this information. Validation is the act of "double-checking“ or verifying data to confirm that it is accurate and factual. Organization of data The nurse uses a written or computerized format that organizes the assessment data systematically. The format may be modified according to the client's physical status.
  • 7. Documenting data: To complete the assessment phase, the nurse records client's data. Accurate documentation is essential and should include all data collected about the client's health status. Data are recorded in a factual manner and not interpreted by the nurse. E.g.: the nurse record the client's breakfast intake as" coffee 240 ml. Juice 120 ml, 1 egg". Rather than as "appetite good".
  • 8. PURPOSE OF ASSESSMENT: • To validate a diagnosis • To provide basis for effective nursing care. • It helps in effective decision making • Basis for accurate diagnosis • It promote holistic nursing care • To provide effective and innovative nursing care • To collecting data for nursing research • To evaluation of nursing care
  • 9. TYPES OF ASSESSMENT Type Aim Time frame 1- Initial assessment Initial identification of normal Within the specified time function, functional status, and frame after admission to a collection of data concerning hospital, nursing home, actual or potential dysfunction. ambulatory healthcare center. Baseline for reference and future comparison. 2- Focus assessment Status determination of a Ongoing process, integrated specific problem identified with nursing care, a few during previous assessment. minutes to a few hours between assessments. Comparison of client’s current Several months (3,6,9 months 3- Time – lapsed status to baseline obtained or more) between assessment reassessment previously, detection of changes in all functional health patterns after an extended period of time has passed Identification of life – AT anytime 4- Emergency threatening situation assessment
  • 10. NURSING DIAGNOSIS Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA, 1997). Steps: Each Nursing Diagnosis has three components: *Label an actual or potential health problems that Nursing care can affect. *Related factors- Factors that may precede, contribute to or be associated with the human response. *Evidence – Signs symptoms that point to the Nursing Diagnosis.
  • 11. TYPES OF NURSING DIAGNOSIS • Actual Diagnosis: An actual diagnosis is a statement about a health problem that the client has, and could benefit from nursing care. An example of an actual nursing diagnosis is: ---Ineffective airway clearance related to decreased energy and manifested by an ineffective cough. • A risk diagnosis is a statement about a health problem that the client doesn't have yet, but is at a higher than normal risk of developing in the near future. An example of a risk diagnosis is: ---Risk for injury related to altered mobility and disorientation.
  • 12. While walking Mrs. Lin to the bathroom, she complains of dizziness: • Ask her if the dizziness is related to an activity • Take her blood pressure in lying and standing positions • Determine what interventions will reduce her dizziness • Later, in the day, check with her if additional episodes have occurred • Teach her to change her position slowly • Formulate the nursing diagnosis “High Risk for Injury related to vertigo secondary to postural hypotension”
  • 13. • A complete nursing diagnosis is written in the format problem related to cause of problem as evidenced by symptoms of problem • An example of such a nursing diagnosis would be Impaired gas exchange related to excessive secretions as evidenced by O2 saturation of 86%.
  • 15. NURSING PLANNING The third step of the nursing process; includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care. The planning of nursing care occurs in three phases: (initial, ongoing, and discharge.) Each type of planning contributes to the coordination of the client’s comprehensive plan of care.
  • 16. The four critical elements of planning 1.Establishing priorities. In establishing priorities, the nurse examines the client’s nursing diagnoses and ranks them in order of physiological or psychological importance. One of the most common methods of selecting priorities is the consideration of Maslow’s hierarchy of needs, which requires that a life- threatening diagnosis be given more urgency than a non life threatening diagnosis.
  • 18. 2.Setting goals and developing expected outcomes A goal is a specific and measurable objective designed to reflect the patient highest level of wellness and independence in function. There are 2 categories in goals. • Short term – Can be met fairly and quickly (hours or days) • Long term – cover a long time span e.g. The patient will be free of infection throughout hospitalization.
  • 19. 3. Developing Expected outcomes Expected outcome define when a patient goal has been met and assist in evaluating the extent to which the Nursing diagnosis has been resolved. e.g. Goal : The patient lung will remain clear post operatively . Expected outcomes: - The sputum will remain white - The patient will remain afebrile - The lungs will be clear to auscultation
  • 21. 4.Planning nursing interventions (with collaboration and consultation as needed) Nursing interventions are treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient / client outcomes. Dependent – a nursing action based on the instruction of another professional. Independent – requires no supervision. Interdependent – actions carried out by the nurse in collaboration with another health care professional. • Nursing interventions must be specifically designed to meet the identified goal. • Each intervention should be supported by a scientific rationale.
  • 23. IMPLEMENTATION While implementing nursing orders, the nurse continues to reassess the client at every contact, gathering data about the client’s responses to nursing activities and about any new problems that may develop. To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills. These skills are distinct from one another. The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity.
  • 24. When implementing interventions, nurses should follow these guidelines: • Base nursing interventions on scientific knowledge, nursing research, and professional standards of care whenever possible. • Clearly understand the order to be implemented and question any that are not understood. • Adapt activities to the individual client, a client’s beliefs, values; age, health status, and environment are factors that can affect the success of a nursing action. • Implement safe care • Provide teaching, support and comfort to enhance the effectiveness of nursing care plans. • Be holistic; view the client as a whole. • Respect the dignity of the client and enhance the client’s self- esteem • Encourage client to participate actively in implementing the nursing interventions.
  • 25. Documenting Nursing Activities, • the nurse complete the implementing phase by recording the interventions and client responses in the nursing process notes. • The nurse may record routine or recurring activities such as mouth care in the client record at the end of shift, while some actions recorded in special worksheets according to agency policy. • Immediate recording helps safeguard the client to prevent double actions.
  • 26. EVALUATION • The last phase of the nursing process, follows implementation of the plan of care, it’s the judgment of the effectiveness of nursing care to meet client goals based on the client’s behavioral responses. When determining whether a goal has been achieved, the nurse can draw one of the three possible conclusions: – The goal was met, that is the client response is the same as the desired outcomes. – The goal was partially met, that is either a short term goal was achieved but the long term was not, or the desired outcome was only partially attained. – The goal was not met.
  • 27. “When goals have been partially met or when goals have not been met, two conclusions may be drawn: • The care plan may need to be revised, since the problem is only partially resolved OR • The care plan does not need revision, because the client merely needs more time to achieve the previously established goals. • So the nurse must reassess why the goals are not being partially achieved.
  • 28. APPENDECTOMY Client assessment database: Activity & rest: May report Malaise Circulation: may exhibit Tachycardia Elimination: May report Constipation of recent onset of diarrhea Abdominal distension, tenderness/ rebound tenderness, rigidity, decreased May exhibit or absent bowel sound . Food/fluid : may report Anorexia , nausea , Vomiting Pain/ Discomfort : May report Abdominal pain around the epigastrium and umbilicus, which may have an insidious onset and become increasingly severe (RLQ) at mc Burney’s point. Respiration: May exhibit Tachypnea, Shallow respirations
  • 29. Diagnostic studies: • CBC: WBC s are often elevated, neutrophil count elevated • Abdominal CT, USG, Abdominal radiographs. Nursing Priorities: • Prevent complication • Promote comfort • Provide information about surgical procedure/prognosis, treatment needs, and potential complications.
  • 30. Discharge Goals: • Complication prevented / minimized • Pain alleviated/controlled • Surgical procedure/ prognosis , treatment understood.
  • 31. Nursing Diagnosis: Risk For infection Outcome criteria: wound healing Actions/ Interventions Rationale Independent Practice / instruct in good hand Reduces the risk of spread of bacteria washing and aseptic wound care. Encourage and provide perineal care Inspect Incision and dressings. Note Provides for early detection of characteristics of drainage from developing infectious process. wound/drains, presence of erythema Monitor vital signs . Note if fever, Suggestive of presence of infection/ chills diaphoresis, changes in developing sepsis, abscess, peritonitis mentation , report if increase abdominal pain. Collaborative Administer antibiotic as appropriate Antibiotics given before appendectomy primarily for prophylaxis of wound infection and continued post operatively
  • 32. Nursing Diagnosis: Risk For deficient fluid volume Outcome criteria: hydration(Maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor, stable vital signs, adequate urine output. Action/Intervention Rationale Independent Monitor Vital signs Variations help identify intra vascular volume. Inspect mucous membrane ; assess skin Indicators adequacy of peripheral turgor and capillary refill. circulation and cellular hydration. Monitor I&O; note urine color Decreasing output concentrated urine concentration, specific gravity. with increasing specific gravity suggests dehydration. Auscultate bowel sounds. Note passing Indicators return of peristalsis , readiness flatus , bowel movement to begin oral intake Provide clear liquids in small amounts Reduces the risk of gastric irritation/ ,when oral resumed vomiting and fluid loss Give frequent mouth care with special Dehydration results in drying & painful care to protect lips cracking of lips and mouth
  • 33. Collaborative Maintain gastric / intestinal suction as To decompress the bowel, promote indicated intestinal rest, and prevent vomiting Administer IV fluids and electrolytes The peritoneum reacts to irritation/ infection by producing large amount of intestinal fluid , possibly reducing circulating blood volume, resulting in dehydration and relative electrolyte imbalances. Nursing Diagnosis: Acute pain related to inflammation / presence of surgical incision. Outcome criteria: report pain relieved / minimized Actions/ interventions Rationale Pain management Independent Assess pain, noting location, Use full in monitoring effectiveness of characteristics, severity (0-10 scale) medication, progression of healing. Changes in characteristics of pain may indicate developing abscess/peritonitis require medical evaluation and interventions
  • 34. Provide accurate , honest information Being informed about progress of to client situation provides emotional support, helping to decrease anxiety Keep at rest in semi fowler's position Relieving abdominal tension, which is accentuated by supine position. Encourage early ambulation Promotes normalization of organ function Provide diversional activities. Refocuses attention , promotes relaxation. Collaborative Keep NPO/Maintain NG suction initially Decreases the discomfort of early intestinal peristalsis and gastric irritation/vomiting Administer analgesics as indicated Relief of pain facilitates cooperation with other therapeutic interventions e.g. ambulation , pulmonary toilet.
  • 35. Nursing Diagnosis: Deficient Knowledge ( regarding condition, prognosis, treatment, self care, and discharge needs.) Outcome criteria: Verbalization of understandings Independent Teaching disease process Identify symptoms requiring medical Prompt interventions reduces risk of evaluation e.g. increasing pain, edema/ serious complications e.g. delayed erythema around wound , presence of wound healing, peritonitis drainage, fever Review post operative activity Provides information client to plan for restrictions, e.g. heavy lifting, exercise, return usual routines. sports, driving Encourage progressive activities as Prevent fatigue, promotes healing and tolerated with periodic rest periods well being Discuss the care of incision , including Understanding promotes cooperation dressing changes, bathing restrictions, with therapeutic regimen, enhancing and return to physician. healing and recovery process.