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8. ANATOMY AND PHYSIOLOGY

17. Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation S > The patient may verbalized: -problem such as loss of sexual 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 Sexual Dysfunction related to altered body structure and function Short term: After 4 hours of nursing interventions the patient will identify stressors in lifestyle that may contribute to the dysfunction Long term: After 3 day of nursing interventions the patients will verbalize understanding of individual reasons for sexual problems >Establish rapport >Monitor vital signs > Obtain sexual history including usual patterns of functioning and level of desires > Be alert to comments of client > identify current stressors in individual situations > Avoid making value judgments >Establish therapeutic nurse-client relationship >Provide ways to obtain privacy >To gain trust >To obtain maintenance data >To maximize communication and understanding >Sexual concerns are often disguised as humor, sarcasm, or offhand remarks > These factors may be producing enough anxiety to cause depression > They do not help the client >To promote treatment and facilitate sharing of sensitive information >To allow sexual expression for individual between partners without embarrassment Short term: The patient identified stressors in lifestyle that contributes to the dysfunction Long term: The patient verbalized understanding of individual reasons for sexual problems

18. Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation S> O> the patient manifested: -Weakness -Pallor -with dry and intact dressing on the area. -Pain over the incision -Irritability -Presence of intact dressing Risk for infection secondary to surgical incision Short term: After 4 hours of nursing interventions, the patient shall identify and demonstrate intervention to prevent infection Long term: After 1 day of nursing interventions, the patient will not have infection >Establish rapport >Monitor V.S. >Note signs and symptoms of sepsis >Provide wound healing such as cleaning of wound >Provide care, change dressing as needed >Encourage increase intake of Vitamin C >Encourage deep breathing exercise >To gain trust >To obtain baseline data >To reduce complication and monitor for infection >To reduce risk for infection >To promote healing to the incision >To prevent infection to increase immune resistance >To increase healing of wound Short term: The patient identified and demonstrated interventions to prevent risk of infection Long term: The patient doesn’t experience infection