Objetivo 4. Caracterizar genéticamente la población de pavo autóctono mexicano
10. Polimorfismo del ADN mitocondrial
10.2. Índices de diversidad
ASSESSMENT DIAGNOSIS BACKGROUND KNOWLEDGE
PLANNING NURSING INTERVENTION
RATIONALE EVALUATION
SUBJECTIVE:
“Sumasakit ang tagiliran ko na may tubo.” as verbalized by the patient.
OBJECTIVE:
(+) Guarding behavior in the abdomen (+) Facial grimacing (+) Distraction behaviors
Pain scale of 7/10
Acute pain related to tissue trauma
secondary to surgical incision as manifested by client
verbalization and pain scale of 7/10
Lung disease
Pneumothorax or accumulation of air in the pleural space
Chest tube thoracostomy
performed as surgical management
Tissue trauma in the right thorax for tube insertion
Acute pain
LONG-TERM:
After 4 hours of nursing interventions, the patient will report pain is relieved or controlled by reporting a lowered pain scale of 4/10
SHORT-TERM:
After 1 hour of nursing interventions, the patient will follow prescribed pharmacological regimen
After 1 hour of nursing interventions, the patient will verbalize
nonpharmacologic methods that provide relief
After 2 hours of nursing interventions, the patient will demonstrate use of relaxation skills and diversional activities
Independent
Assess pain, noting locations, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.
Provide accurate, honest information to patient or significant others.
Encourage ambulation.
Provide diversional activities.
Collaborative
Administer analgesics as indicated.
Useful in monitoring effectiveness of medication and progression of healing.
Changes in characteristics of pain may indicate developing complications requiring prompt medical evaluation and intervention.
Being informed about the progress of situation provides emotional support, helping to decrease anxiety.
Promotes normalization of organ function
Refocuses attention, promotes relaxation, and may enhance coping abilities.
Relief of pain facilitates cooperation with other therapeutic intervention such as ambulation
LONG-TERM:
(GOAL MET)
After 4 hours of nursing interventions, the patient was able to report pain is relieved or controlled by reporting a lowered pain scale of 4/10
SHORT-TERM:
(GOAL MET)
After 1 hour of nursing interventions, the patient was able to follow prescribed
pharmacological regimen
After 1 hour of nursing interventions, the patient was able to verbalize nonpharmacologic methods that provide relief
After 2 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills and diversional activities ASSESSMENT DIAGNOSIS BACKGROUND
KNOWLEDGE
PLANNING NURSING INTERVENTION
RATIONALE EVALUATION
SUBJECTIVE:
“Hindi ako makagalaw nang maayos dahil sa tubo sa tagiliran ko.” as verbalized by the patient.
OBJECTIVE:
(+) Limited range of motion
(+) Difficulty in turning
(+) Slowed movement (+) Decreased reaction time (+) Postural instability
Impaired physical mobility related to pain /
discomfort secondary to tissue trauma as manifested by limited range of motion
Lung disease
Pneumothorax or accumulation of air in the pleural space
Chest tube thoracostomy
performed as surgical management
Tissue trauma in the right thorax for tube insertion
Presence of pain and discomfort
Impaired physical mobility
LONG-TERM:
After 4 hours of nursing interventions, the patient will participate in ADLs and desired activities
SHORT-TERM:
After 1 hour of nursing interventions, the patient will verbalize
understanding of situation and individual treatment regimen and safety measures
After 2 hours of nursing interventions, the patient will demonstrate
techniques / behaviors that enable resumption of activities
After 1 hour of nursing interventions, the patient will maintain and increase strength and function of affected body part
Independent
Note emotional / behavioral responses to problems of immobility
Support affected body part using pillows / rolls
Administer medications for pain relief prior to activities as needed
Encourage participation in self-care and other activities Encourage adequate intake of fluid / nutritious food
Collaborative
Consult with physical / occupational therapist as indicated
Feelings of frustration / powerlessness may impede attainment of goals
Maintains position of function and reduces risk for pressure ulcer
Promotes maximal effort / involvement in activities
Enhances self-concept and sense of independence
Promotes well-being and maximizes energy production
Develops individual exercise / mobility program
LONG-TERM:
(GOAL MET)
After 4 hours of nursing interventions, the patient was able to participate in ADLs and desired activities
SHORT-TERM:
(GOAL MET)
After 1 hour of nursing interventions, the patient was able to verbalize understanding of situation and individual treatment regimen and safety measures
After 2 hours of nursing interventions, the patient was able to demonstrate techniques / behaviors that enable resumption of activities
After 1 hour of nursing interventions, the patient was able to maintain and increase strength and function of affected body part
ASSESSMENT DIAGNOSIS BACKGROUND KNOWLEDGE
PLANNING NURSING INTERVENTION
RATIONALE EVALUATION
SUBJECTIVE:
“Hindi ako makakain masyado dahil sa tubo sa tagiliran ko.” as verbalized by the patient.
OBJECTIVE:
Verbalization of loss of appetite (+) Loss of weight (4kg)
Imbalanced nutrition: less than body requirements related to loss of appetite secondary to pain /
discomfort as manifested by loss of weight
Lung disease
Pneumothorax or accumulation of air in the pleural space
Chest tube thoracostomy
performed as surgical management
Tissue trauma in the right thorax for tube insertion
Presence of pain and discomfort
Imbalanced nutrition:
less than body requirements
LONG-TERM:
After 4 hours of nursing interventions, the patient will demonstrate
progressive weight gain toward goal
SHORT-TERM:
After 1 hour of nursing interventions, the patient will verbalize
understanding of causative factors when known and necessary interventions
After 2 hours of nursing interventions, the patient will demonstrate
behavior / lifestyle changes in order to regain appropriate weight
Independent
Assess weight; measure / calculate body fat and muscle mass
Note age, body build, strength, activity / rest level Evaluate total daily food intake. Obtain a diary of calorie intake, patterns and time of eating
Promote pleasant, relaxing environment and socialization when possible
Prevent / minimize unpleasant odors / sights Collaborative
Consult dietitian / nutritional team as indicated
Establishes baseline parameters
Helps determine nutritional needs
Reveals possible changes that could be made in client’s intake
May enhance the patient’s intake
May have a negative effect to appetite / intake
Implements interdisciplinary team management
LONG-TERM:
(GOAL MET)
After 4 hours of nursing interventions, the patient was able to demonstrate progressive weight gain toward goal
SHORT-TERM:
(GOAL MET)
After 1 hour of nursing interventions, the patient was able to verbalize understanding of causative factors when known and necessary interventions
After 2 hours of nursing interventions, the patient was able to demonstrate behavior / lifestyle changes in order to regain appropriate weight
VII: CONCLUSION
This case study had a great impact to the group, it served as a realization for the group. It required thorough research about the client’s condition against both theory and the large comparative environment. In this study, the objectives are important. Formulating objectives before conducting a case study of Pneumothorax was very challenging because it was unfamiliar for the group.
After doing this case study, the group attained and formulated nurse-centered objectives. The group was able to enhance and to develop their knowledge, skills, and attitudes to provide effective nursing care to the patient conducive to good health. The group was able to come up with a comprehensive presentation of the disease condition by means of correct presentation of the data gathered through the use of nursing process. The group was able to review the anatomy and the physiology of Pneumothorax. The group became familiarized with the nursing interventions appropriate for the client’s condition. And by means of this case study, the group was able to apply their knowledge, skills and attitudes to those patients having the same condition.
With the help of proper education rendered during the period of assessment and care, the client was able to acknowledge the group as part of the health care team, and cooperate with the group in all the activities and management done. The client was able to understand recognize the disease condition. The client learned the importance of healthy lifestyle and complies with the treatment at hand.
VIII: BIBLIOGRAPHY
Books:
Bare, Brenda G., Cheever, Kerry H., Hinkle, Janice L., Smeltzer, Suzanne C.
“Brunner &Suddarth’s Textbook of Medical- Surgical Nursing,” 10thed. Vol.2
Doenges, Marilynn E., Moorhouse, Mary Frances, Murr, Alice “Nurse’s Pocket Guide,” 11thed.
Joyce M. Black & Jane Hawks “Medical Surgical Nursing” 7thedition . pp. 1302-1314 Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2
Lewis et.al Medical Surgical Nursing 6th ed. pp.1142-11472011 Lippincotts Nursing Guide Drug Handbook Online Resources:
http://digestive.niddk.nih.gov/statistics http://en.wikipedia.org/wiki
http://www.google.com.ph/imglanding?q=lungs+respiratory+system & um=1 & hl=tl & sa=N & tbs=isch:1 & tbnid=RQfphKO5xG7KVM: & imgrefurl=http://www.ama-assn.org – picture
http://www.surgeryencyclopedia.com http://www.pneumothorax/stats-country.htm http://.www.wikinursing.com