VI.

Nursing Care Plan (NCP)

NURSING PRIORITY # 1

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION INTERVENTION RATIONALE

INDEPENDENT:
1. Maintain patency of Chest tube thoracostomy by keeping tubing free of kinks & ensuring proper tidaling in water seal compartment - Chest tube drainage system must remain intact to remove abnormal gases and fluids from clients chest to maintain proper negative intrapleural pressure and facilitate adequate ventilation.

EVALUATION

Subjective cues:  Chest pain (pleuritic-like): dili kaayo maka ginawa ug lalom kay sakit as verbalized by patient.  SOB: kulang ang hangin as verbalized by patient Objective cues:  general pallor  elevated RR: 28 cpm  shallow respiratory depth  nasal flaring  decreased O2 sat: 89%  diminished breath sounds  unsymmetrical chest: right side

Ineffective Breathing Pattern r/t fluid and air accumulation in peritoneal and pleural cavities secondary to gunshot trauma

SHORT TERM: After 20 minutes of nursing interventions, the client will : y return demonstrate and verbalize importance of deep breathing and coughing exercises y agree to perform deep breathing and coughing exercises at home after discharge

SHORT TERM: After 20 minutes of nursing interventions, the goals were met.

2. Ensure sterile saline, sterile gauze, and plaster are at bedside.

- Should the drainage tube

be accidentally detached from collection chamber, end of tube can immediately be submerged in sterile saline to maintain water seal and prevent exacerbation of pneumothorax; Should the drainage tube be accidentally removed from chest, thoracostomy incision site can be immediately covered with sterile gauze taped with plaster to reduce risk of infection and exacerbation of pneumothorax. These safety measures ensure integrity of patients primary postoperative medical management.

After 8 hours of nursing interventions, the goals were met

LONG TERM: After 16 hours of nursing interventions up until discharge, the goals were met.

After 8 hours of nursing interventions, the client will : y have achieved and sustained improved respiratory parameters, including normal respiratory rate and depth, and O2 saturation of at least 90%

Ineffective breathing pattern: Inspiration and/or expiration that does not provide adequate ventilation.

3. Position client comfortably in semiFowlers or high-Fowlers

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with greater anteroposterior diameter

 HGB = 9 g/dl  HCT = 25.8 %

(Doenges, 151)

y exhibit decreased pallor

LONG TERM: After 16 hours of nursing interventions up until discharge, the client will : y have maintained normal respiratory rate and depth, and O2 saturation of at least 95% y exhibit flush skin y have been observed performing deep breathing and coughing exercises on own volition

position. 4. Instruct client to perform deep breathing and coughing exercises every hour: a.) inhale deeply through nose b.) hold breath for 3-5 seconds c.) exhale with pursed lips d.) repeat at least 5-10 times e.) cough deeply 5. Instruct client how to physically reduce pain by flexing knees and splinting abdomen area with pillow when coughing and changing positions.

- Elevated head position facilitates diaphragmatic excursion and optimal lung expansion. - Expands lungs and promotes effective gas exchange, blood oxygenation, and CO2 elimination

DEPENDENT:
1. Administer oxygenation by nasal cannula as prescribed at 4 L/min

- Splinting can reduce pain by supporting wounds and applying diffuse pressure over surrounding areas to close gate control. Flexing knees can reduce pain by decreasing abdominal tension. Reduced pain better encourages patient to perform deep breathing and coughing exercises to improve ventilation.

- Improves oxygen blood saturation. - Decreases pain to promote comfort and decrease oxygenation demands.

2. Administer celecoxib 200mg PO BID as prescribed COLLABORATIVE:

Refer patient to respiratory therapist, if

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available.

- Respiratory therapists have the expertise to provide a more individualized exercise regimen targeting muscles of respiration.

NURSING PRIORITY # 2

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION INTERVENTION RATIONALE

EVALUATION

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Subjective cues:  Pt verbalizes diffuse pain over surgical incision sites of 1 out of 5 (5 as most painful) upon rest, 3 out of 5 upon activity

Acute pain r/t stab wound and thoracostomy and exploratory laparotomy surgical incisions

SHORT TERM: After 20 minutes of nursing interventions, the client will: y return demonstrate and verbalize importance of deep breathing exercises After 30 minutes of nursing interventions, the client will : y report a decrease in pain level from 3 to 1 (activity) y exhibit decreased guarding over surgical wounds

INDEPENDENT:
1. Assist with wound care and dressing. - Proper wound hygiene prevents infection that would exacerbate pain. - Supports surgical incision, thereby reducing pain.

SHORT TERM: After 20 minutes of nursing interventions, the goals were met. After 30 minutes of nursing interventions, the goals were met.

2. Assist with proper placement of abdominal binder. 3. Apply cold packs to near incisions for 20minute intervals. 4. Instruct client to flex knees.

- Cold has analgesic effects.

Acute Pain:

 Preference for sitting position verbalized by patient. Objective cues:  thoracostomy surgical incision, 1in left 5th ICS  Exploratory laparatomy surgical incision, 11in midline around umbilicus  guarding of incisional site near lower abdomen  grimacing

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. (Doenges, 586)

LONG TERM:
- Bent knees reduce abdominal tension, thereby reducing pain in the area. - An uncomfortable environment would otherwise exacerbate pain.

After 72 hours of nursing interventions up until discharge, the goals were met.

LONG TERM: After 72 hours of nursing interventions up until discharge, the client will : y report complete absence of pain y be able to walk and change positions more easily, without pain

5. Provide comfort measures (e.g. tuck in bed linens, promote a quiet environment, wipe client periodically to keep him dry, fan client to keep him cool) 6. Provide diversional activities (e.g. conversation, therapeutic touch and massage) 7. Facilitate range of motion exercises such as flexion and extension of extremities, and/or assist with ambulation as much

- These distract patients attention from pain.

- Exercise promotes blood

circulation, thereby expediting healing of wounds and consequent reduction of pain.

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 elevated RR: 28 cpm  general weakness  limped gait y utilize various independent pain management measures (e.g. deep breathing and imagery on own accord)

as patient can tolerate.

DEPENDENT:
1. Administer PO pain meds Celecoxib 200mg BID PO 2. Administer PO antibiotics Cefuroxime (Zinacef) 500mg BID, PO

Analgesics relieve pain. Antibiotics prevent infection that would otherwise aggravate pain

COLLABORATIVE:
Refer patient to physical therapist, if available.

Physical therapist has expertise to provide patient with a more individualized regimen of physical activity. This increases feelings of well being and promotes healing and may decrease pain directly by promoting release of endogenous opioids.

NURSING PRIORITY # 3

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ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION INTERVENTION RATIONALE INDEPENDENT: 1.) Provide positive atmosphere, while acknowledging difficulty of the situation for the client & encourage to ambulate progressively 2.) Provide health teaching in the client regarding the:
y organization and time management technique while on activity y negative factors affecting activity intolerance y techniques such as deep breathing (pain), pauses & distraction - helps to minimize frustration and re-channel activity

EVALUATION

Subjective cues:  Luya man kayo ako paminaw sa tibuok na lawas ui, dili jud ko kalihok lihok kay musakit lagi ang akong mga tinahian, magpatabang pa gali ko sa ako mama as verbalized by the patient

Activity Intolerance related to generalized weakness from recent surgery & pain felt on the incision sites upon activities

SHORT TERM: After 30 minutes of nursing interventions, the client will: y Identify negative factors affecting activity intolerance and eliminate or reduce their effects when possible y Use identified techniques (e.g. deep breathing, pauses, distraction etc.) to enhance activity tolerance LONG TERM: After 2 hours of nursing interventions, the client will: y Participate willingly in necessary/ desired activities Report measurable increase in

SHORT TERM: After 30 minutes of nursing interventions, the goals were met.

LONG TERM:
- to provide adequate knowledge to client / enhance

After 2 hours of nursing interventions the goals were met.

Activity Intolerance

 Oo, maglisod na dayon ko ug ginhawa kung maglakaw2x o lihok2x ako mao na nga wa koy gana manglihok as verbalized by the patient  SOB Objective cues:  RR 28cpm  Increase in BP

Insufficient physiological or psychological energy to endure or complete required or desired daily activities
(Doenges, 69)

3.) Provide enough air from the electric fan or from the window 4.) Develop & adjust simple activity like brushing his teeth, walking towards the comfort room (provide assistance if necessary)

- to enhance clients ability to participate in the activity (tolerable) - to increase patients tolerance to activities, little by little; promote independence in self-care activities as tolerated ; prevent overexertion

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from 110/80 to 130/70 mmHg y  Pallor (if prolonged activities)  Slow, guarded movements

activity tolerance Balances activity and rest Demonstrate a decrease in physiological signs of intolerance (e.g. HR & BP within normal limits, pallor, dyspnea)

5.) Provide comfort & safety measures on the activity & alternate activity & rest 6.) Adequate fluid intake COLLABORATION: Referral to other disciplines such as therapy , recreation / leisure specialists as indicated

- to protect client from injury; minimize exhaustion & helps balance O2 supplu & demand - to maintain hydration

- to develop individually appropriate therapeutic regimens

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