Sheena's File

8/8/2019 Sheena's File

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Nursing Diagnosis: Acute pain related to disruption of skin tissue secondary to Below Knee Amputation

Findings Scientific Basis Expected Outcomes NursingInterventions

Actual Outcomes

S = sakit akongsamad sa tiil asverbalized by patient.= pain scale of 6 / 10

O= grimaced face*guarding behavior*restlessness*diaphoresis*irritability

Diabetic ulcers is atypical sequence in hedevelopment beginswith a soft tissue injury

of the foot, formation ofa fissure between thetoe and in area of dryskin or formation ofcallus

Ref: Doenges,NANDA,9th

ed.,FA Davis,2004S.C. Smeltzer&B.G.Bare,MedicalSurgicalNursing,Vol.2,LWW,2004

Within 8 hrs of Nursinginterventions, thepatient will verbalizedecrease in pain

sensation and decreasepain scale of 3-4/10.

I: monitor vital signsR; to asses furtherabnormalitiesI: place patient in

comfortable position.R: to help decreasepain sensation anddecrease painsensation.I: apply wounddressing

R: to minimize furtherinfection and preventsmicroorganismI: encourage pt. toverbalize painR: to help pt. ease thepainI:instruct pt. to do

deep breathingexercisesR: to promotecirculation and easepainI: Instructed pt./SO to

After 8 hrs ofnursinginterventions,patient had

verbalized decreasedof pain sensationwith the scale of 4

/10


2/18

turn the patient tosides every 2hoursR: to prevent bed soresI:DI:give medications asprescribed byphysician:Sultamicillin 750mg BID

For pain.


3/18

Nursing Diagnosis: Impaired Physical mobility related to musculoskeletal impairment sec. to below knee amputation


Actual Outcomes

S= sakit kau ilihok satuo tungod sa akongsamad sa likod asverbalized by patient

O= limited range ofmotion,*difficulty turning,

*Slowed movement

Activity modificationsare prescribed toreduce back irritationand prevents

debilitation frominactivity. Most clientsdo not require bed rest,in fact, more than 4days of bed rest can bedebilitating and slowrecovery. The client istaught to minimize thestress of lifting by usinggood body mechanics,keeping objects closeto the body and toavoid twisting whenlifting. Sitting mayaggravate pain and

clients who sit at workshould always changeposition.

Within 8 hrs of nurse-patient intervention,the patient will be ableto verbalize

understanding of thesituation andparticipate inrepositioning program

I: Provide care on aroutine basis.R: Provides opportunityof evaluate healing and

note complicationsI: assists with specifiedROM exercises foraffected body part.R: Prevents deformitieswhich can developrapidly and could delayhealing process.I: Instruct pt. to lie inside lying position astolerated.R: strengthens muscleand prevents bed soreson other parts of thebody

I: provide trochanterrolls as indicated.R: prevents externalrotation of lower limbstump

After 8 hours ofNursinginterventions, thepatient had

verbalizedunderstanding of thesituation andparticipate inrepositioningprogram


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Ref:Doenges,NANDA,9thed.,FA Davis,2004,MedicalSurgical Nursing,

Vol.2,LWW,2004S.C.Smeltzer&B.G. Bare

I: techniques / assist

with transfertechniques and use ofmobility aids, such ascrutches or walker.R: facilitates self careand patientsindependence. Proper

transfer techniquesprevents shearing

/abrasionI: provide medicationfor pain relief:Sultamicillin 750mg BIDR: to relieve pain


5/18

Nursing Diagnosis: Impaired skin integrity related to altered circulation evidence by tissue damage


Actual Outcomes

S= no verbal cuesO= disruption of skinsurface,*facial grimaces when

apply pressure,*invasion of body

structure,* destruction of skinlayers

Ulcers or pressure soresis one of the mostcommon dermatologiccomplain. When

neglected, this may leadto impaired skin integritywith excoriation,redness, raised area,infection and changes inpigmentation

Ref: Doenges,NANDA,9thed.,FA Davis,2004S.C. Smeltzer&B.G.Bare,MedicalSurgicalNursing,Vol.2,LWW,2004

Within 8 hrs of Nursingintervention, patientwill express decrease inpain sensation and

would understand thetreatment and regimenfor ulcers

I: monitor vital signsR: to indicate furtherabnormalitiesI: encourage client to

do deep breathingexercisesR: to promotecirculationI: apply wounddressingR: to prevent infectionsI: encourage client todo diversional activitiessuch as back rubbingand talking to clientR: to help client easethe pain.I: changed positionfrequently.

R: to prevent soresDI: give remedy ofmedications asprescribed byphysician. FlamazideOD R:to alleviate pain

After 8 hrs ofNursing interventionPatient nowexpresses

decreased of painsensation andunderstands thetreatment andregimen for ulcers.


6/18

Nursing Diagnosis: Self care deficit related to pain and physical impairment secondary to Diabetes Mellitus

Findings Scientific Basis ExpectedOutcomes

NursingInterventions

Actual Outcomes

S: Di nako makaatiman sa akongkaugalingon kay dikayo ko maka lihok-lihok tungod sa

kasakit.:as verbalizedby patient.

O: Inability to washbody or body parts

y Foul smelly Inability to get

out of bedy With short-

dirty nailsy Unclean

disheveledapperance

y Dry bodyy Warm

temperature

The management ofchronic disease is oftendifficult for both theclient andclinician. This is because

the client often hasmultiple medications totake as well as having tochange life stylebehaviors such as dietand exercise. Achievingoptimal health status forthe elderly client with achronic disease requiresmutual participation byboth the client and theHealth Care Provider(HCP).



Within 8 hours ofnursing intervention,the patient and SOwill be able to identifyindividual areas of

weaknesses / needsand demonstratetechniques to meetself-care needs.

I: Established rapportR:to help build ptstrustI: assessed patientcondition.

R:to know furthercomplicationsI: monitored V/S andI&O.R: to assess forbaseline dataI: Encouraged patientto

Verbalized thoughtsand feelingsR: to know patientsneedsI: Assisted anddemonstrated pt andSO on Self- care

needs such asComplete Bed bath ortepid sponge bathR: to make patientfeel comfortableI: assisted and

After 8 hours ofnursing intervention,the patient and SOverbalizes hisindividual areas of

weaknesses / needsand had maintainedto be clean andpresentable.


7/18

demonstrated pt/SO

on oral careR: to make ptcomfortable andprevents halitosisI: Provided privacyduring personal careactivities

R: to preventunnecessary exposureI: Encouraged patientto eat propernutritional foodsR: to help pt. meetnutritional needsI: Provided safety byraising side railsR: to provide safety topt


8/18

Nursing Diagnosis: Risk for further infections related to decreased leukocyte function and delayed healing secondary to

DIABETES MELLITUSFindings Scientific Basis Expected Outcomes Nursing

InterventionsActual Outcomes

S: no verbal cuesO: = disruption of skinsurface,*invasion of body

structure,* destruction of skinlayers*edema*swelling is present* labs: increasedWBC:11.7x10 mg/dl*decreasedlymphocytes to 11%

Besides generalizedimpairments ofimmunity, othernonimmunologic,

anatomically specificfactors may contributeto an increased infectionrisk. Macrovasculardisease andmicrovasculardysfunction may resultin compromised localcirculation leading todelayedresponse to infection7and impaired woundhealing. Unawareness oflower extremity traumadue to sensory

neuropathy may resultin inadequate attentionto minor wounds andsubsequent increasedinfection risk.

Within 8 hrs of Nursinginterventions, thepatient and SO will beable to verbalized

understanding ofindividual causativefactors and identifyintervention to helpreduce or preventinfection

I: established rapportto ptR:to gain pts trustI: assessed pt condition

R: to know furthercomplicationsI: monitored pts v/sand I&OR: for baseline dataI: encouraged pt andSO on proper handwashingR: for defense againstnosocomial infectionI: Applied wounddressing as PRNR:to prevent infectionsI: Instructed pt ontechniques to protect

integrity of skin likepetroleum jelly or mildlotionR:to prevent skindryness / lesions

After 8 hrs ofNursinginterventions, thepatient was afebrile

and Verbalized:kahibalo nakounsaon pag likay oginpeksyon, sama sapag hugas ogkamot og tarong ogpaglimpyo sa akongmga samad.andLastly, Patientand SO haddemonstratedproperly techniqueson preventinginfection.


9/18



I:Assisted in giving

medication asprescribed by physicianCefuroxime 750mgq8 hrsR: causing therapeuticeffects abactericidalactions and prevents

bacteria growth


10/18


11/18

report any

discomforts todrug

Name ofDrug

Classification Mechanismof Action

Indications Contraindication Side Effects NursingResponsibilit

ies


12/18

GENERIC

NAME:Cefuroxime

Pt. dose:750mg q8hrs

TRADE

NAME:

CeftinZenacef

GENERAL

CLASSIFICATIONS:

Anti- ineffective

FUNCTIONALCLASSIFICATIONS:

Cephalosphorin

Binds to

bacteria cellwallmembranecausingtherapeuticeffects abactericidal

actions

Serious

lowerrespiratorytractinfections,UTIs skinand skinstructure

infectionsand jointinfections,septicemiaandmeningitisandgonorrhea

Contraindicated to

pts hypersensitiveto drug. Usecautiously to ptshypersensitive topenicillin because ofcross sensitivity ofbeta lactam anti-

biotic

-fever,

headaches,dizziness,phlebitis, rashes,chills, pruritus

-Obtain

specimen forculture andsensitivityBeforeadministration, ask pt if heis allergic to

penicillin-monitor PTand INR inpatients withimpaired Vit.Ksynthesis.-tell pt to takedrug

As prescribeeven if hefeels better-instruct pt totake oral formwith food-tell pt to

report of s/sxof any allergicreactions


13/18


14/18

Name of Drug Classification Mechanism of

Action

Indications Contraindication Side

Effects

Nursing

Responsibilitieses

GENERIC

NAME:Promethazine

Pt. dose:

35mg (ONCALL)

TRADENAME:

Phenergan

GENERAL

CLASSIFICATIONS:

Respiratory tract

drugs

FUNCTIONALCLASSIFICATIONS:

Anti emetics, anti-histamines

Blocks theeffects ofhistamine, hasinhibitory effectson the

chemoreceptorstriggers in themedulla,resulting, inantiemeticsproperties altersthe effects ofdopamine in the

CNS. Possessignificant anticholinergicactivity.Produces CNSdepression byindirectly

decreasedstimulationdecreasedstimulation ofthe CNSreticular system

For variousallergicconditionsand motionsickness.

Postoperative sedationandpreventionof nauseaand vomitingadjunct toanesthesia

andanalgesics

-hypersensitivity,to comatosepatient, prostatichypertrophy,bladder neck

obstruction

Neurolepticmalignantsyndrome

confusionsedation,dizziness,fatigue,blurredvision

-monitor BP,pulse, andrespiratory ratefrequently-assess for level

of sedation andrespiratorydepression-monitor pt forneurolepticmalignantsyndrome-stop drug for 4

days beforediagnostic skin-pronouncedsedative effectlimits use inambulatory pt-Reduce GI

distress by givingdrug with food-warn pt to avoidalcohol andhazardousactivities


15/18

Name of

Drugs

Classification Mechanism of

Action


Effects

Nursing

Responsibilities


16/18

GENERIC

NAME:Ampicillin250mg IVTT

TRADENAME:

Apo-Ampi+

GENERAL

CLASSIFICATIONS:

Therapeutic; anti-infectives.Pharmacologic;aminopenicillins beta

lactam inhibitorsFUNCTIONALCLASSIFICATIONS:Penicillin

-binds to

bacterial cellwall resulting incell death;spectrum isbroader than ofpenicillins.Therapeutic

effects;bactericidalactionsspectrum activeagainststreptococci,pneumococci,enterococci

Treatment of

skin and skinstructureinfections,soft tissueInfections.Otitis media, sinusitis,

resp.enfections,meningitis,septicemia

- hypersensitivity

to penicillins orsulbactam.

Nausea

andvomiting,dizziness,fatigue,blurredvision,lethargy,

hallucinations,depression, veinirritation,diarrhea,abdominal pain,

anemia,pain atinjectionsite,hypersensitivityreactions

-Assess patient

for infections-Obtain a historybefore initiatingtherapydetermineprevious use ofactions

-obtain specimenfor culture andsensitivity beforegiving drug-monitor sodiumlevel-decrease dosagein pt with renal

impairment-tell pt to takethe entirequantity ofexactly asprescribed evenif he feels better

-instruct pt totake the oralform onan emptystomach, / 1-2hrs after meal


17/18

Name of

Drug

Classification Mechanism

of Action


Effects

Nursing

ResponsibilitiesGENERICNAME:SilverSulfaniazide(Once aday).

TRADENAME:

FlamezineCream

GENERALCLASSIFICATIONS:

Topical drugs

FUNCTIONAL

CLASSIFICATIONS:Local ant- infectives

A broadspectrumsulfonamidethat acts oncellmembrane

and cell wall ;itsbactericidalfor manygram-positiveand gram-negativeorganism

- to preventor treatwoundinfections insecond andthird degree

burns

-hypersensitivity-bathe patientsdaily, if possible-inspect clientsskin daily

-pain, rash,skincoloration,pruritis, skinnecrosis,leucopenia.

-use steriletechnique toprevent woundcontamination-use drug only onaffected area-inspect clients skin

daily and note anychanges-monitorsulfaniazide leveland renalfunctions.-tell physicianifhepaticor renal

dysfunction occurs-discard darkenedcream becausedrug may beineffective-instruct pt topromptly reportany adverse

reaction-tell pt that he maydevelop sensitivityto sun


18/18

Name ofDrug

Classification Mechanismof Action

Indications Contraindication SideEffects

NursingResponsibilities

GENERICNAME:

TRAMADOLHYDROCHLORIDE

TRADE

NAME:ULTRAM

GENERALCLASSIFICATION

S:

CNS drugs

FUNCTIONAL

CLASSIFICATIONS:Opioids analgesics

A centrallysyntheticanalgesiccompoundnotchemically

related toopioid

Thought tobind to opioidto opioidreceptors &inhibitreuptake ofnorepinephrine& serotonin

Moderate tomoderatelysevere pain

Hypersensitivity todrugs or otheropioids, inbreastfeedingwomen, & in thosewith acuteintoxication from

alcohol, hypnotics,centrally actinganalgesics, opioidsor psychotic drugs.serioushypersensitivityreactions can occur,usually after the 1st

dose

Use cautiously in pts@ risk for seizuresor respiratorydepression, in ptswith inc intracranialpressure or head

injury, acuteabdominalconditions, renal orhepatic conditions

CNS:dizziness,vertigo,headache,anxiety,confusion,

malaise,nervousnessCV:proteinuria, urinaryfrequencyGI: n/vabdominalpain,dyspepsia,flatulence,anorexia,drymouth,

diarrhea

Reassess pts level ofpain @ least 30 min afteradministration

Monitor dose & notifyphysician if RR>12cpm

Monitor bowel & bladderfunction. Anticipate needfor laxative

For better analgesiceffect, give drug beforeonset of intense pain

Monitor pt @ risk forseizures

Monitor for drugdependence andWithdrawal symptomsmay occur if drug isstopped abruptly.

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