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College of Nursing WHO Collaborating Center For Leadership in Nursing Development Nursing Interventions Ii (N-107)
College of Nursing WHO Collaborating Center For Leadership in Nursing Development Nursing Interventions Ii (N-107)
Emphasize importance of
avoidance of eating raw and
unwashed food. Eating
raw/unwashed food places the
client at risk for opportunistic
infections.
Objective:
Subjective: Chronic pain Chronic Pain is Goal: The The goal was met/partially
- “Masakit yung dito related to described as an client will met/unmet as evidenced by:
ko, simula pa nung penile unpleasant report gradual □ Increased participation in
napansin ko na may carcinoma sensory and reduction of activities of recovery
bukol ako last year” emotional pain, as □ Performance of non-
as verbalized by the experience evidenced by pharmacologic ways of reducing
client while pointing arising from indicators pain
to and showing actual or □ Reduction of grade in pain scale
inguinal and pubic potential tissue Objectives: NOC: Comfort □ Provocation:
area damage or 1. Client will NIC: Emotional Support Level __________
described in be able to 1. Perform a comprehensive 1. Client □ Palliation:
Objective: terms of such verbalize assessment of pain to include identifies __________
PQRST Assessment: damage feeling of any location, characteristics, onset, presence of pain □ Quality of
Provocation/ (International pain and duration, frequency, quality, pain:________
Palliation: Association for discomforts. intensity or severity, and □ Region/
- The pain is the Study of precipitating factors of pain. Pain Location:
worsened by Pain); sudden or is a subjective experience and __________
standing/putting slow onset of must be described by the client in □ Severity:
pressure on the any intensity order to plan effective treatment. Universal Pain
inguinal area from mild to Assessment
such as sitting severe, constant Encourage the client to verbalize Tool Grade:
upright or recurring feelings, perceptions and fears. ___/10
Quality: without an Expression allows the □ Timing:
anticipated or identification of pain level, as only ________
- Client describes predictable end the client can judge the level and
the pain as a and a duration of distress of pain.
stabbing greater than six
sensation in his (6) months. Acknowledge pain.
flesh (sa loob) Acknowledging the client when he
Radiation: verbalizes/shows pain validates
- Pain radiates the client and allows for trust and
from inguinal good rapport between him and the
area to right SN.
costovertebral
angle Provide psychological support and
Severity: motivation. Assuring the client
- Rated 5/10 while that support is available and help
under pain will be given if needed by the
medication client; either by the SN or his
during present S/O will allow for greater
assessment feeling of comfort by the patient.
Temporal: NOC: Pain
- The pain is 2. Client will NIC: Pain management Control Demonstration
constant; client be able to 2. Assess client’s vital signs q 2 h. 2. Client’s of the following
describes it as demonstrate Changes in vital signs may return □ Deep breathing
persisting even the indicate acute pain and demonstration exercises
with or without nonpharmacol discomfort. of non- □ Positioning
pain medication, ogic ways of pharmacologic □ Rest
just in varying reducing pain Teach the client and his S/O the ways of □ Distraction
degrees of nonpharmacologic ways that can reducing pain. □ Relaxation
severity help her in reducing experienced □ Massage (c/o
pain (relaxation, distraction, SO)
- Observed mass massage, deep breathing exercises,
in left inguinal proper positioning, rest, sleep).
area, 5 x 5 cm in Teaching the client and significant □ BP: 120/80
size, does not others maximize opportunities for □ PR: 60-80
elicit pain self-control over manifestations of beats/min
response when pain, as they themselves are the □ RR: 16-20
palpated ones implementing the method of breaths/min
pain control. The use of □ Temp:
- Observed noninvasive pain relief measures 36.537.5 C
tenderness in can increase the release of □ O2 sat >95%
pubic area, elicits endorphins and work alongside
pain response the therapeutic relief of pain □ (-) shortness of
when palpated medications. breath
□ (-) dyspnea
- Visibly Encourage adequate periods of rest □ (-) use of
observable veins and sleep and meeting comfort accessory
from right side of needs. Rest prevents undue fatigue muscles
pelvis up to and stress which can contribute to
lateral area of the pain and increased attention to □ Provocation:__
waist pain. __
□ Palliation:
Demonstrate and assist client in _____
deep breathing exercises. DBEs □ Quality of
are easy to follow and do even in pain:________
bed and contributes to pain _
reduction via slowing the heart □ Region/Locatio
rate and distracting the patient n
from his pain. □ Severity:
Universal Pain
Position client in a comfortable Assessment
position wherein he feels the least Tool Grade:
pain (Low Fowler’s position) ___/10
To promote circulation and □ Timing:
prevent extensive tissue pressure ________
which is his reported cause of
exacerbation of pain.
□ Identifies
Provide massage to the client and nonpharmacolo
encourage the significant other to gic technique
perform massage for the client. to reduce pain
Massaging gently the areas distal that she prefers
to the site of pain induces the to utilize
release of serotonin and
endorphins which is the body’s
anti-pain mediators and can
improve client’s disposition, as
well as improving circulation.
Administer medications as
prescribed. Whenever applicable,
administer pain medications/direct
client in taking pain medications
that have been previously
prescribed by the physician for
pain management.
Subjective: Risk for Disturbed Body Goal: The The goal was met/partially
- “Paano ko ba disturbed Image is client will met/unmet as evidenced by:
gagawin, parang body image confusion in demonstrate □ Demonstrate a willingness and
positive ba?” as mental picture of acceptance of ability to resume self-care/role
stated by the client, one’s physical appearance, as responsibilities
when asked to self. As the evidenced by □ Initiate new or reestablish
describe how he sees client is indicators. contact with existing support
himself. undergoing systems.
- “Nawalan ako ng chemotherapy
buhok tapos with multiple
namayat talaga ako chemotherapeuti
ng husto simula c
nung chemotherapy” c agents, the Objectives: Encourage the client to verbalize Verbal feedback Client verbalizes
as stated by the body’s immune The client will feelings especially his perception experiences and
client. system is implement of himself or feelings about his identifies
- “Tumigil na kami depressed. As effective appearance. Frequent verbal support system
sa pagtatalik ni the drugs target coping contact with the caregiver and S/O
misis nung napansin rapidly dividing patterns. facilitates for gradual acceptance
ko na may bukol na cancerous cells, and building of trust and rapport.
ko” as stated by the many normal
client. cells are Encourage the client to ask
- states previous use destroyed along questions about health problem
of chemotherapeutic the process. Hair treatment, progress and prognosis.
agents follicles are The client may be hesitant to
structures in the approach the staff or his attending
Objective: skin filled with physician because of negative
- (+) hair loss blood vessels selfconcept or feelings of
- (+) cachexia responsible in inferiority, therefore the SN must
- Client, when asked the production of reach out to the client and make
to describe how he hair. These cells him feel that he is allowed and
sees himself, are one of the even encouraged to know more
displayed hesitation fastest growing and be participant in directing his
and slight confusion cells in the body care.
on how to respond dividing every 1
adequately to 3 days.
Chemo agents, The client will Provide opportunity to share with Client verbalizes
targeting rapidly resume social people going through similar experiences and
dividing cells activities. experiences. Having people with identifies
↓ similar experiences to share their Verbal feedback support system
Hair follicles are thoughts and feelings assists in
subsequently accepting the different bodily
destroyed along changes and being more
with cancerous comfortable with it.
The client will Discuss the hair loss and where Verbal feedback Client accepts
maintain they may occur (head, eyelashes, current hair loss
healthy levels eyebrows; axillary, pubic and leg and where it has
of self- hair). Hair is a very important part occurred.
esteem. in a person’s body image and loss
may lead to decreased levels of self-
esteem; feelings of frustration
References:
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Renwick W, Pettengell R, Green M. Use of filgrastim and pegfilgrastim to support delivery of chemotherapy. Twenty years of clinical experience.
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