NURSING

INTERVENTION
CLASSIFICATION
PUSAT PENGEMBANGAN BAHASA
UNIVERSITAS HARAPAN BANGSA
 DETERMINE THE INTERVENTION FOR
MR.G ‘S CASE
Mr. G, aged 73, was hospitalized due to a medical diagnosis of
Pulmonary TB. The client complained of shortness of breath. The
client said that he was coughing up blood for an hour ± 5 tbsp. The
client was frightened of the expelled blood while coughing. He also
suffered from chest pain with scale 5 out of 10 to cough up with
sputum. The results of his physical examination were BP 140/90
mmHg, P : 120 bpm, T : 36.8 ‘C, RR : 30 breaths/ minute, and
ronchi breathing. The client’s face lookes tense and nervous. The
patient said that he has never had this condition before.
 POSSIBLE
INTERVENTION
 PLANNING INTERVENTION
Problem Planning Intervention
Ineffective Airways Airway Management (3140)
Clearance • Open the airway by using the chin lift or jaw thrust technique,
as appropriate
• Position patient to maximize ventilation potential
• Perform chest therapy, as appropriate
• Encourage slow, deep breathing; turning; and coughing
• Instruct how to cough effectively
• Auscultate breath sounds, noting areas of decreased or
absent ventilation and presence of adventitious sounds
• Position to alleviate dyspnea
Acute Pain Pain management (1400)
• Perform a comprehensive assessment of pain to include
location, characteristics, onset/duration, frequency, quality,
intensity or severity of pain, and precipitating factors.
• Ensure that patient receives attentive analgesic care
• Teach the use of non-pharmacological techniques
 PLANNING INTERVENTION
Problem Planning Intervention
Anxiety Anxiety reduction (5820)
• Use calm reassuring approach
• Provide a factual information concerning diagnosis,
treatment, and prognosis
• Encourage verbalizations feelings, perceptions, and
fears
• Identify when level of anxiety changes
• Instruct patient in use of relaxation techniques
• Observe for verbal an nonverbal signs of anxiety
ASSIGNMENT
WHAT TO DO
◇ It is an individual assignment
◇ Analyze the case of Mrs. A and
make the nursing care plan using
the outline provided.
◇ Type your answer in Ms. Word and
convert to PDF.
◇ Upload your work in the assignment
pocket of meeting 5.
 CASE
Mrs. A, a house wife aged 48 years old, complained of lumps on her left
hand which was getting worse around 2 days before she was admitted to
the hospital. Totally there are three hard and palpable lumps found on
her left hand. The first lump appeared 10 months ago but hasn’t been
treated yet since the patient didn’t feel any pain. It was followed by the
second lump appearing 6 months ago, and the last lump two days ago
which was accompanied by pain. Each lump’s size is approximately 3 cm.
No visible sores, redness and mobility found on the lumps. She felt a
continuous stabbing pain with a scale of 6 which increases every time she
is doing daily activities using her hand. She stated that she didn’t
consume any medication, had no smoking and drinking habit. The results
of assessment showed that BP: 125/70 mmHg, P: 84 bpm, RR: 20 bpm,
and T: 36,8 °.
NCP OUTLINE