NURSING DIAGNOSIS
______
Potential ineffective airway clearance R/T non-productive cough and effect of anesthetics. / GOALS
______
Short-term:
Client’s lung sounds will remain clear during my shift.
Long-term:
Client’s lung sounds will
remain clear throughout her
Hospitalization. / INTERVENTIONS
______
1. Ensure client knows how to cough and deep-breathe effectively and explain the importance of it to them.
2. Assist client with coughing and deep-breathing about 10 times q1-2 h while awake.
3. Provide for pain-relief before having the client cough and deep breathe.
4. Provide a minimum of 2500 ml. fluids per day.
5. Encourage the use of an incentive spirometer 4-6 times every 1-2 hours.
6. Assist client to get out of bed and ambulate a short distance each shift.
7. Monitor breath sounds, respiratory rate and depth and temperature every 4 hours. / RATIONALE
______
1. Will encourage client to participate in the coughing and deep-breathing.
2. Will aid in the removal of secretions and will expand lungs.
3. To encourage cooperation & a less painful experience.
4. Will help to liquefy secretions and therefore assist with removal.
5. Will help to expand the lungs more fully.
6. Will increase respiratory expansion.
7. To detect early signs of consolidation and/or infection. / EVALUATION
______
Client’s lung sounds remained clear throughout my shift.
Client was able to DB and C and use incentive spirometer and had 1500 ml of fluid intake.
NURSING DIAGNOSIS
______
Alteration in comfort related to pain in surgical incision as evidenced by rating abd. pain @ 8 out of 10 and grimacing with movements. / GOALS
______
Short-term:
1. Client will verbalize pain relief to tolerable level (2-3) 1 hour after given analgesic.
2. Client will state that changing positions and ambulating is more tolerable (2-3) by the end of the shift.
Long-term:
1. Client will be able to tolerate oral analgesics instead of injections within 48 hours. / INTERVENTIONS
______
1. Assess location, quality, intensity and site of pain throughout shift.
2. Assess both verbal and non-verbal indicators of pain.
3. Use pain-rating scale as per hospital policy.
4. Administer analgesics prn and give promptly when asked.
5. Teach splinting of abd. area when coughing and deep breathing, laughing or sneezing.
6. Administer analgesics prior to ambulation.
7. Teach client non-pharmacological pain relief measures (eg. Distraction, imagery).
8. Continually assess effectiveness of pain relief. / RATIONALE
______
1. To allow for appropriate intervention and documentation.
2. Both verbal and non-verbal cues will indicate pain intensity and relief.
3. Provides accurate determination of pain intensity and relief.
4. Provides pain relief, decreases stress and anxiety.
5.Teaches client ways to help decrease pain.
6. Ensures ambulation as pain free as possible, increases likelihood client will agree to ambulate again.
7. Teaches client alternative pain relief measures if pain meds not yet due.
8. Helps to ensure adequate pain relief. / EVALUATION
______
Short-term:
Client verbalized pain relief with analgesics and stated pain decreased to between 2-4 at end of shift.
- Goal met.
Long-term:
Unable to assess at this point.
Would assess in 48 hours.