III. LIST OF PRIORITIZED NURSING DIAGNOSIS PROBLEM 1.
Acute Pain related to difficulty of breathing secondary to compression of the spinal cord COVERT/OVERT Overt Actual ACTUAL/POTENTIAL JUSTIFICATION Pain is the first prioritized, since it is the actual problem being experienced by the patient. Hence, it needs an immediate action so as not to prolong the intensity of pain felt by the patient. According to Maslow s Hierarchy of needs, safety and security needs should first be met before higher needs can be addressed. Abdellah s 21 nursing problems also prioritized the physical comfort of the patient. This is the second prioritized problem since this factor may aggravate pain being felt by the patient,it is a physiologic need and could be lead to danger on the part of the patient. Hence, there isa break or trauma in the skin specifically at the scrotal area which decreases primary defense of the body that accounts for risks in the patient s safety such as bleeding, infection and could aggravate pain felt by the patient. And also the trauma is located below the bladder just behind the rectum, wherein the area is usually moist that encourages bacteria that could lead to infection. Therefore, it is a need to make an immediate action. It is also present in Abdellah s 21 nursing problems which is To promote safety through prevention of accidents, injury,
2. Impaired skin integrity related to tissue trauma secondary to Bilateral Orchiectomy
Overt
Actual
3. Impaired physical mobility r/t Paraplegia
Overt
Actual
or other trauma and through the prevention of the spread of infection This is classified as the third priority due to the decrease or loss of feelings, function in the lower extremities the patient couldn t perform activity of daily living which increases chances that without proper physical mobility the patient might develop other complications such as pressure sores. Impotence and various degrees of urinary and fecal incontinence may also occur. As Henderson specifies that need to move and maintain desirable posture. This is the fourth priority according to the concept of OFFTERAS, the first A stands for activity. Enhancing mobility has many beneficial effects like it increase muscle strength which in return may already solve the following prioritized problems. Mobilization also promotes peristalsis that may promote bowel elimination. This is prioritized as the fifth because According to Maslow s Hierarchy of Needs, this is a Physiologic problem that could According to ABCs of life, this is an airway problem that needs to be prioritized. According to OFFTERAS, this is an
4. Impaired transfer mobility r/t loss of muscle function
Overt
Actual
5. impaired tissue perfusion r/t impaired physical mobility
Overt
Actual
6 Risk for infection r/t tissue trauma secondary to bilateral orchiectomy Risk for infection r/t invasive procedure
Covert
potential
7. risk for constipation r/t immobility
Covert
Potential
8. death anxiety r/t underlying disease
Overt
actual
oxygenation problem that needs to be given first priority. Infection needsimmediate action sinceit poses a great danger to the patient if leftunaddressed. The problem is only the risk to the patient acquiring infection if aseptic technique won t be practiced. According to Henderson s 14 basic human needs, eliminating body wastes comes after drinking [Link] is a physiologic need that should be addressed so as to prevent further complications. Abdellah s 21 nursing problem which is To facilitate the maintenance of elimination. Abdellah s 21 nursing problem which is to identify and accept positive and negative expressions, feelings, and reactions
9. Anxiety
Overt
actual
Although the patient is concern about the finances of his stay in the hospital, this are not threat to life.
IV. NURSING PROPER P: Difficulty of breathing A1: Acute pain related to difficulty of breathing secondary to compression of the spinal cord. ASSESSMENT OBJECTIVES S: Goal: Patient will be able to feel no pain Nasakittipananguyekko, awantiplemasngarumuarngemmarigatanakng LTO: After 48 hours of nursing interventions the patient will be able to aag-anges. Claimed by the patient. relieve signs and symptoms of pain. Haankonga kaya ngabumangon, nu agtugawak mas STO: After 8 hours of nursing lalongahaanakngamakaangesngausto ta interventions the patient will be able to: nasakit. Calimed by the patient Isunga nu manganakketmaorasannak ta, a) Manifest ease in breathing tipanagtilmonkoketnasakit. Claimed by the b) Manifest clear breathe paient sounds c) Manifest clear breathe sounds O: d) Verbalizes method that relieves Weak and fatigability noted pain Grimacing noted e) Verbalize any feelings of pain or Uses abdomen as accessory muscle for discomfort breathing Slow movement on the bed Inability to perform activity of daily living Needs assistance on physical mobility With positive bibasal crackles upon auscultation on lung field. Prefer head to be elevated. With symmetrical chest expansion. Vital signs as follows: bp:130/80 mmHg, RR: 18cpm, PR: 75 bpm, T:36.0C
INTERVENTIONS Dx: Assessed the characteristics of pain. Assessed respiratory rate, rhythm, depth, symmetry and use of accessory muscles. Observed signs and symptoms of respiratory distress such as irritability. Monitored for feeding intolerance, abdominal distention and emotional stressors.
EVALUATION
Tx: Assisted in repositioning of the patient Promoted safety and security by raising side rails Give medications as ordered Provided comfort by providing extra pillows Provided adequate fluid intake Edx Encouraged the patient to adequate rest Encouraged to increase fluid
intake. Encouraged the Significant others to perform back tapping. Taught the significant others the importance of back tapping
A2: Impaired skin integrity related to tissue trauma secondary to Bilateral Orchiectomy ASSESSMENT S: OBJECTIVES INTERVENTIONS EVALUATION
O: