NURSING CARE PLAN NAME OF STUDENT: NAME OF CLIENT: xxx DIAGNOSIS OR CLINICAL IMPRESSION: Pancreatic mass probabaly malignant

CUES S: * Female * 62 years old * Post-operative patient (Operation: March 23, 2010) * Masakit yung kanang kamay ko kasi mali ata yung pagkakasaksak nung IV. Sumasakit 'yung sutures kasi. O: *(+) palpable mass liver edge 4 cm below RCM * Normal Weight BMI = 20.76 Height: 170 cm. Weight: 60 kg. * Vital signs: (Mar. 29, 2010) RR = 24/min Temp. = 37.6 C P = 64/min BP = 120/60 *Latest hematology results: (March 21, 2010) Decreased RBC, Hgb and Hct. RBC = 2.93 x 10 ^12/L NURSING DIAGNOSIS Risk for Infection related to compromised host defenses secondary to probable pancreatic cancer BACKGROUND KNOWLEDGE Medical factors predisposing to infection include: immunocompromised: steroids, immunosuppressants, AIDS, connective tissue disease, cancer or leukaemia, chemotherapy (very dangerous as signs diminished) previous infection: rheumatic fever, TB or jaundice surgical conditions: gallstones, diverticular disease, prostatism and prolapse recent surgery or procedure, dentistry and minor injury family history or other close contact of infection medication including selfmedication and blood products malnourished GOALS AND OBJECTIVES GOAL: At the end of the nursing intervention, Mrs. xxx will remain infection-free and report risk factors associated with infection and precautions needed. OBJECTIVES: After the nursing intervention, xxx will: 1. Describe 2 methods of transmission of infection. 2. Verbalize understanding of individual/causative risk factors in her own words. 3. Describe the influence of nutrition on prevention of infection in her own words. 4. Maintain adequate hydration. 5. Demonstrate meticulous hand washing procedure. 6. Perform preoperative body shower or scrubs when indicated. 7. Demonstrate proper deep breathing exercises, coughing technique and ROM exercises.

DATE OF ASSIGNMENT: March 22, 2010 CIVIL STATUS: Separated AGE: 62 SEX: F WARD: 4 BED: 2 NURSING INTERVENTIONS AND RATIONALE The student nurse will: 1.Instruct the client about the various modes of transmission of microorganisms and risk factors. R: This is done to prevent the spread of microorganisms. 2. Enumerate to the individual and family members the signs and symptoms of infection. R: This is done for the client to be able to assess herself for possible infection and inform the nearest health professional and be given immediate care. 3. Encourage and maintain caloric and protein intake in diet in accordance with prescribed soft diet. R: This is done to strengthen the immunity without compromising the prescribed diet. 4. Inform the client about the importance of maintaining adequate hydration. R: Adequate hydration helps in regulating the body temperature and removing excess wastes and toxins. 5. Inform and demonstrate to the client, the proper hand washing technique and procedure. EVALUATION By the end of the nursing intervention, Ms. xxx will able to: 1. Accurately describe 2 methods of transmission of infection. 2. Verbalize understanding of individual/causative risk factors in her own words. 3. Describe the influence of nutrition on prevention of infection in her own words. 4. Maintain adequate hydration. 5. Properly demonstrate meticulous hand washing procedure. 6. Perform preoperative body shower or scrubs when indicated. 7. Demonstrate proper deep breathing exercises, coughing technique and ROM exercises.

SOURCE: http://www.gpnotebook.co.uk /simplepage.cfm? ID=1543897156 Nosocomial infection is an infection caught while hospitalized. Most nosocomial infections are due to bacteria. Since antibiotics are frequently used within hospitals, the types of bacteria and their resistance to antibiotics is different than bacteria outside of the hospital. Nosocomial infections can be

Hgb: 98 g/L HCT: 0.292 Increased Neutrophils and WBC. Neutrophils = 0.896 WBC = 12.10 10^9/L *Antibiotic Therapy (Metronidazole 1cap TID x 2 days) * NSS infused at 31 gtts at right arm, (+) inflammation

serious and difficult to treat. SOURCE: http://www.medterms.com/script /main/art.asp?articlekey=10430

R: Good hand washing is the first line of defense against the spread of many illnesses. 6. Perform/instruct in preoperative body shower/scrubs when indicated. R: This is done to empower the client with knowledge about what are effective ways to prevent infection. Preoperative body showers are done to maintain cleanliness of patient before operation. 7. Encourage early ambulation, deep breathing, coughing, position change. R: This is done for the mobilization of respiratory secretions.

S: Medyo kinakabahan siyempre. I think that is normal. We do not know what to expect. I just use prayers to calm down. Client cried when the nun said that she could not administer the holy sacrament the day of her surgery. O: BP = 120/60 RR = 24/min PR = 64/min (+) sleep

Anxiety (moderate) related to actual or perceived threat to biologic integrity secondary to invasive procedures

Anxiety is a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships.

GOAL: At the end of the nursing intervention, Mrs. Xxx will relate an increase in psychological and physiologic comfort. OBJECTIVES: After the nursing intervention, Mrs. Xxx will: 1. Explain the importance of preoperative laboratory tests in her own words. 2. Verbalize understanding of bowel and skin preparation and need to remove all makeup and jewelry prior to surgery. 3. State her own understanding of the procedure to be done and

The student nurse will: 1. Explain the need for preoperative laboratory tests R: The more information a client has, the more she is reassured. 2. Discuss bowel and skin preparation and the need to remove all jewelry, nail polish, make-up, etc. prior to surgery. R: Discuss preparations to empower client. 3. Briefly discuss the procedure to be done and what the client could expect from it. R: The more information a client has, the more she is reassured.

After the nursing intervention, Ms. xxx will: 1. Explain the importance of preoperative laboratory tests in her own words. 2. Verbalize understanding of bowel and skin preparation and need to remove all make-up and jewelry prior to surgery. 3. State her own understanding of the procedure to be done and what could be expected 4. State the need for restriction food and oral fluids for at least 8

Anxiety on the unkniwn, especially surgery, is natural and common. Moderate pain increases in the arousal state to a point where the person expresses feelings of tensions, nervousness or concern. SOURCE:
Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004). Fundamentals of nursing (7th ed). Philippines:

disturbances, weakness, faintness, fatigue Gastroscopy results: Postendoscopic diagnosis: duodenal mass probably malignant, 1 VS infiltration, hiatal hernia S: * Female * 62 years old * Post-operative patient (Operation: March 23, 2010) * Masakit yung kanang kamay ko kasi mali ata yung pagkakasaksak nung IV. Sumasakit 'yung sutures kasi. Pain rating for pain in sutures: 5 O: *(+) palpable mass liver edge 4 cm below RCM * Vital signs: (Mar. 29, 2010) RR = 24/min Temp. = 37.6 C P = 64/min BP = 120/60 *Latest Acute Pain related to tissue trauma secondary to surgery

Pearson Prentice Hall

what could be expected 4. State the need for restriction food and oral fluids for at least 8 hours prior to surgery. 5. Demonstrate ambulation, leg exercises, deep breathing and coughing exercises.

4. Explain the need for restriction of food and oral fluids for at least 8hours prior to surgery. R: The more information a client has, the more she is reassured. 5. Demonstrate the need for ambulation, leg exercises, deep breathing and coughing exercises. R: This are nonpharmacological methods used to lessen anxiety. 1. Explain causes of pain to the person, if known. R: The more information a client has, the more she is reassured. 2. Relate how long the pain may last. R: The more information a client has, the more she is reassured. 3. Explain diagnostic procedures and tests in detail by relating discomforts and sensations that will be felt. R: The more information a client has, the more she is reassured. 4. Discuss the reasons why an individual may experience increased or decreased pain (fatigue, or presence of distractions). R: The more information a client has, the more she is reassured. 5. Encourage family support and to to give attention also when pain is not exhibited. R: Family support increases

hours prior to surgery. 5. Demonstrate ambulation, leg exercises, deep breathing and coughing exercises.

Pain is an unpleasant and highly personal experience that may be imperceptible to others, while consuming all parts of the person's life.

Goal: After nursing intervention, Mrs. Xxx will relate relief after a satisfactory relief measure. Objectives: After nursing intervention, Mrs. Xxx will: 1. Explain causes of pain to the person, if known. 2. Relate how long the pain may last. 3. State her own understanding of procedure and give discomforts and sensations that will be felt. 4. State reasons why an individual may experience increased or decreased pain (fatigue, or presence of distractions) 5. Verbalize increase of relief with family support 6. Rest during the day and have uninterrupted sleep at night 7. Select and use a method of distraction during acute pain.

After nursing intervention, Mrs. Xxx will: 1. Explain causes of pain to the person, if known. 2. Relate how long the pain may last. 3. State her own understanding of procedure and give discomforts and sensations that will be felt. 4. State reasons why an individual may experience increased or decreased pain (fatigue, or presence of distractions) 5. Verbalize increase of relief with family support 6. Rest during the day and have uninterrupted sleep at night 7. Select and use a method of distraction

Pain is a physical and emotional experience.

Effective pain management is an important aspect of nursing care to promote healing, prevent complications, reuce suffering and prevent the development of incurable pain states.

Visceral pain is pain arising from organs or hollow viscera.

Source:
Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004). Fundamentals of nursing (7th ed). Philippines: Pearson Prentice Hall

hematology results: (March 21, 2010) Decreased RBC, Hgb and Hct. RBC = 2.93 x 10 ^12/L Hgb: 98 g/L HCT: 0.292 Increased Neutrophils and WBC. Neutrophils = 0.896 WBC = 12.10 10^9/L *Antibiotic Therapy (Metronidazole 1cap TID x 2 days) * NSS infused at 31 gtts at right arm, (+) inflammation

reassurance of patient. 8. Select and use non-invasive pain-relief measures. (relaxation techniques, music therapy, moment of discussion) 6. Provide person with opportunities to rest during the day and with periods of uninterrupted sleep at night (must rest when pain is decreased). R: Rest gives patient time to relax and remove self from pain. 7. Teach a method of distraction during acute pain. R: A method of distraction can be used to alleviate pain. 8. Teach non-invasive painrelief measures. (relaxation techniques, music therapy, moment of discussion) R: This are nonpharmacologic methods of reducing pain.

during acute pain. 8. Select and use noninvasive pain-relief measures. (relaxation techniques, music therapy, moment of discussion)

References: Doenges, M., Moorhouse, M. F. & Murr, A. (2006). Nurses pocket guide: Diagnoses, prioritized interventions and rationales. Philadelphia: F.A. Davis Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004). Fundamentals of nursing (7th ed). Philippines: Pearson Prentice Hall Smeltzer, S & Bare, B. (2004). Medical-surgical nursing. N.p.: Lippincott Williams & Wilkins