need care plan help

[oracle389]

hi. um, i just hoped to ask for help in making a nursing care plan for this patient of mine. medical diagnosis of intramural myoma, chief complaint is enlarged abdomen. has undergone TAHBSO. is currently experiencing intermittent gnawing pain on the surgical site. also, needs help in certain ADLs like bathing, toileting, grooming and hygiene.

hope you can help me with what nursing diagnoses i will use. i'll most probably prioritize the rest and comfort of the patient, then the motor function.

also, i'm having troubles with the rationale for each Independent intervention, because we need to present it.

hope to hear from your ideas.

thanks a lot.

[DCJ3]

here are some you can use:

*acute pain r/t surgical procedure

*imbalanced nutrition: less than body requirements r/t decreased ability to ingest or digest food

*risk for ineffective tissue perfusion: peripheral r/t immobility, abdonimal surgery resulting in stasis of blood flow,

*risk for infection r/t invasive procedure

*constipation or risk for constipation r/t decreased activity, decreased fluid intake, anesthesia, narcotics

*anticipatory grieving r/t change in body image, loss of reproductive status

*ineffective coping r/t situational crisis of surgery

*nausea r/t manipulation of gi tract, postsurgical anesthesia

*disturbed sleep patttern r/t pain, lack of sleep privacy/control, interruptions for treatment

*dressing/hygiene self care deficit r/t pain

*urinary retention r/t anesthesia, pain, fear

*anxiety r/t change in health status, hospital environment

*activity intolerance r/t pain, surgical procedure

b.

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i hear and i forget

i see and i remember

i do and i understand~ old proverb

[DCJ3]

By the way you prioritize your diagnoses based on maslow's heriarchy, not necessarily by patient comfort and rest.....As far as interventions go, you should buy Nursing Diagnosis Handbook by Ackley - it has all the interventions you would do plus the rationales for it....Here's the website for it http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/. It doesn't but you have to look through the medical conditions to actually find your nsg dx but if you do it has the actual interventions on it. For example here's the page for acute pain: http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/index.cfm?plan=36.

This is Maslow's heriarchy so you can organize the nsg dx, by the way the Ackley book has the dx arranged in order of priority so that saves a step:

PHYSIOLOGIC NEEDS

oxygen, circulation

water-salt balance

food balance

acid-base balance

waste elimination

normal temperature

sleep, rest, relaxation

activity, exercise

energy

comfort

stimulation

cleanliness

sexuality

SAFETY NEEDS

protection from physical harm

protection from psychological threat

freedom from pain

stability

dependence

predictable, orderly world

BELONGINGNESS NEEDS

love and affection

acceptance

warm, communicating relationships

approval from others

unity with loved ones

group companionship

SELF-ESTEEM NEEDS

sense of value, usefulness

high evaluation of self

adequacy

self-reliance

goal achievement

mastery and competence in skills

independence

endurance

ESTEEM FROM OTHER'S NEEDS

recognition

dignity

appreciation from others

dominance over others

importance, influence

reputation of good character

attention

status

SELF-ACTUALIZATION NEEDS

personal growth and maturity

awareness of potential

increased learning

full development of potential

improved values

religious philosophic satisfaction

increased creativity

increased reality perception and problem-solving abilities

less rigid conventionality

less of the familiar, and more of the novel

greater satisfaction in beauty

increased pleasantness

less of the simple, more of the complex

[tencat]

Howdy! I think it basically boils down to: If it threatens the essential life functions of the patient, it's the biggest priority. Essential functions include Airway, Breathing, Circulation, nutrition needs, etc.

[oracle389]

thanks for the inputs!

[JR816, BSN, RN]

This is awesome information. I will bookmark it!!