care plan colon

8/2/2019 Care Plan Colon

1/16

CUES NSG. DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subj. Maglisod najud na siya ug lihok-

lihok nga dili

alalayan, as

verbalized by

significant other.

Obj.-decreased muscle

endurance, strength

and control

- Tremors

- Muscle Rigidity

- Decreased ability to

initiate movements

- Impairedcoordination of

movement

- Limited ROM

- Postural

disturbances

- Impaired ability to

carry out ADL

Impaired physicalmobility related to

neuromuscular and

musculoskeletal

impairment as

evidenced by inability

to move purposely

within physical

environmentincluding bed

mobility , transfers

and ambulation.

After 3-4 hours ofgiving health

teachings and nursing

intervention, patient

will:

a)Strives toward

improved mobility

*Participates in

exercise programdaily

*Patient is free of

complication of

immobility as

evidenced by intact

skin, absence of

thrombophlebitis and

normal bowel pattern

INDEPENDENT:>Allow patient to

perform task at his

own rate. Do not rush

the patient.

Encourage

independent

activities as able and

safe.> Keep side rails up

and bed in a low

position

>Turn and position

every 2 hours or as

needed

> perform passive

and active range of

motion to all

extremities

>Supervise and assist

with ambulation

>Family members

want to perform task

rather than enable

patient to do it,

thereby slowing the

patients recovery and

reducing self-esteem.

>to promote safeenvironment

> to optimize

circulation to all

tissues and relieve

pressure

>to promote increase

of venous return,

prevent stiffness, and

maintain muscle

strength and

endurance.

>Activity is important

to reduce hazards of

immobility.

After 3-4 hours ofgiving health

teachings and nursing

intervention, patient

showed eagerness

towards improving

mobility by exhibiting

willingness to

participate on dailyexercise program.

>Significant others

and watchers learn

the precautionary

measures to prevent

complications ofimmobility specially

proper skin care.


2/16

>Encourage patient

to lift feet and takelarge steps while

walking

>Encourage the

patient to take warm

bathes and receive

massage

> Reinforce principlesof progressive

exercise ,

emphasizing that

joints are to be

exercised to the point

of pain , not beyond.

> Instruct the patient

to take frequent restperiods to overcome

fatigue and

frustrations

> Teach postural

exercises and walking

techniques to offset

shuffling gait andtendencies to learn

forward

a. Instruct the

patient to use broad

based gait

b. Have the patient

>to improve balance

and minimize

shuffling.

> to help relax

muscles

>No pain, no gain is

not always true

>To improve balance

and minimizeshuffling. A broad-

based gait helps

improve balance


3/16

make a conscious

effort to swing arms,

raise the feet whilewalking, use a heel

toe gait, and increase

the width of stride

> Remove

environmental

barriers

> Provide tips for

getting in and out of

chair

>Encourage liquid

intake of 2-3L a day

unlesscontraindicated

>Clean, dry and

moisturize skin and

use anti pressure

devices as

appropriate

DEPENDENT:

COLABORATIVE:

- Consult physical and

occupational

therapist about aids

- to facilitate ADL andsafe ambulation and

promote muscle

strengthening

-to optimize

hydration status and

prevent hardening of

stool

-to prevent

breakdown


4/16


Subj.

Ginagmay na lang na

siya ug kinan-an kay

maglisod siya ug

tulon as verbalizedby significant others.

Obj.- inability to ingest

food

-decreased function

in swallow/gag reflex

- Weight loss of 4kg

-on soft diet

- Documented intake

below requiredcaloric level

-patient weighs 10%

below ideal body

weight

Alteration in

nutrition; less than

body requirements

related to motor

difficulties withfeeding, chewing and

swallowing as

evidenced by reduced

appetite and weight

loss of 4 kg.

After 2-4hrs of giving

nursing intervention,

patient will

Short-term:>significant others

will verbalize and

demonstrate

selection of

foods/meals that will

achieve a cessation of

weight loss

>patient will take

time while eating and

swallow without

aspiration

Long-term:

Maintain optimal

nutritional status, asevidenced by weight

gain, adequate oral

intake.

INDEPENDENT:

-Allow time for meals

and avoid rushing the

patient.

-Offer high calorielow volume

supplements

between meals.

- Suggest smaller

meals and additional

snacks

- Place patient in a

high fowlers position

for eating and

drinking

- Assist with oral

hygiene emphasize

the importance ofgood oral hygiene

- Supervise patient

during meals. Avoid

distractions

- Teach the patients

to think through the

- To avoid

frustrations.

-To provide additional

caloric intake.

- To promote easy

swallowing

-To avoid aspiration

-Good oral hygiene

increases appetite

- To help patients

focus on swallowing



significant others

demonstrated

understanding onproper food

selection.

>Understand the

implication of proper

safe and conducive

way of eating topromote appetite.


5/16

sequence of

swallowing close lips

with teeth together;lift tongue up with

food on it; then move

tongue back and

swallow while tilting

head forward.

- Instruct the patient

to chew deliberatelyand slowly, using

both sides of mouth

- Tell the patient to

make conscious effort

to control

accumulation of

saliva by holding headupright and

swallowing

periodically

- Have the patient use

secure, stabilized

dishes and eating

utensils

-Provide thickened

food rather than

watery fluid foods

COLLABORATIVE

-


6/16

- Consult the speech

therapist to evaluate

swallowing

- Consult dietitian for

needed changes in

food consistency and

for caloric counts


Subj.

Dili na kayo namo

masabtan ang iyang

inistoryahan as

verbalized bysignificant others.

Obj.

-

- Difficulty in

articulating words

- Monotonous voice

tones- Slow, slurred speech

**Impaired verbal

communication

related to decreased

speech volume,

slowness of speech,and inability to move

facial muscle as

evidenced by slurred

speech difficulty in

articulating words.



patient will

>Communicatesneeds

>Be encourage to

practice speech

exercises

INDEPENDENT:

-Maintain eye contact

when speaking

-Teach the patient

facial exercises and

breathing methods to

obtain appropriate

pronunciation,

volume, and

intonation.

a. Take a deep

breath before

speaking to increase

the volume of sound

and number of words

spoken with each

breath.

-Promote focus and

attention and

encourages patient.

-To reduce rigidity



patient is able to

communicate his

needs adequately asevidenced by using

sign language or facial

expression

>Is able to use

alternative method of

communication as

indicated


7/16

b. Exaggerate

pronunciation and

speak in shortsentences; read aloud

in front of a mirror or

into a tape recorder

to monitor progress.

c. Exercise facial

muscles by smiling,

frowning, grimacing,and puckering.

-Learn how the

patient expresses

needs and wants

particularly non

verbal messages such

as widening of theeyes responses

-Try to device a

commutation system,

perhaps using cards

or pictures of familiar

objects, before verbal

communicationbecomes too difficult.

- Encourage

compliance with the

medication regimen

-We can understand

patient even if they

are unable to speak.

We should not isolate

patient by ceasing to

communicate withthem.

-Patient can indicate

correct card by hitting

it with hand, grunting

or blinking the eyes.


8/16

-Suggest referral to

speech therapist

- Encourage patient

to practice reading

aloud

- Provide alternative

communication aids

as needed

COLABORATIVE :

- Consult speech

therapist if indicated


S-cues:Dili lage siya kaayo

makaihi, makaihi lage

usahay pero

ginagmay ra oud

kayo,as verbalized

by significant other.

Objective Cues:> Absent or

decreased urine

output( bladder distention

>Abdominal

discomfort

Alteration in urinaryelimination;

Retention related to

high urethral

pressure caused by

the disease process

as evidenced by

decrease (30

ml/hour)

>will appear more

comfortable

>Encourage oralfluids/ administer IV

fluids for adequate

hydration, but do not

push fluids or

>Initiate methods to

facilitate voiding

* Encourage fluids

*Position patient inupright position in

toilet if possible

*place bedpan /urinal

Bedside commode

within reach

*Encourage patient

to void every 4 hours

>Rapid filling of thebladder can

precipitate complete

urinary retention

After 8 hours ofnursing intervention

patients had a

complete bladder

emptying thru

indwelling catheter

>Patient appeared

more comfortable

and relieved


9/16

*Offer cranberry juice

if its available,

Dependent:

>Restore flow of

urine by inserting an

indwelling catheter

>to keep urine acidic ,

this will help prevent

infection becausecranberry juice

contains hippicuric

acid.

>Indwelling

cathtetherization is

used to allow freedrainage of the

bladder


Subj. Pila na na sya

ka adlaw na walay

libang libang as

verbalized by

significant other

Obj.

>Abdominal

distention

>Frequent but non

productive desire to

Alteration in normal

bowel elimination;

Constipation related

to diminished motor

function and

inactivity as

evidenced by

abdominal distention

and frequent but

non- productive

desire to defecate.

After 4 hours of

giving nursing

intervention patient

will:

>pass soft form stool

at a frequency

perceived as normal

by the patient

>significant others

will verbalize the

INDEPENDENT:

- Encourage and

provide daily fluid

intake if 2 liters per

day if not

contraindicated

- Encourage increase

in fiber diet (ex. Raw

fruits, vegetables)

- Optimized hydration

and prevent

hardening of stool

- Fiber passes through

the intestine

essentially

unchanged. When it

After 4 hours of

giving nursing

intervention

significant other

verbalized

understanding on the

measures that will

prevent constipation


10/16

defecate

>Straining at stools

>Passage of hardfeces

measures that will

prevent recurrence of

constipation

-

Increase patient

physical activity by

planning ambulation

periods if possible

- Offer a warm

bedpan if he is unable

to go to the bath

room, put him in a

high fowlers position

with knee flex

- Obtained a raised

toilet seat to

encourage normal

position

- Encourage patient

to follow regular

bowel regimen

DEPENDENT

- Administer lacxative

such as Lactulose

30cc PO OD @ hours

of sleep

reaches the colon it

forms a gel which

adds bulk to the stooland makes defecation

easier

- Ambulation an

abdominal exercises

strengthen abdominal

muscles and facilitate

defecation

-Disposition best

utilizes gravity and

allows for effective

valsalva manuever


11/16


Subj.pasensya namo

usahay sakong bana

maam kay usahay

sapoton siya, naguol

gyud na siya sa iyang

sitwasyon, as

verbalized bysignificant other

Obj. Cues:

>irritability

> mood swings

>inappropriate use of

defense mechanism

Ineffective coping

related to physical

limitations and loss

of independence as

evidenced by

irritability, mood

swings andinappropriate use of

defense mechanism.

After 2-4 hours of giving

health teachings and

interventions, the

patient will:

a) Demonstratepositive coping

by decreasingirritability

b) Physicalsymptoms such

as fatigue and

headache will be

lessened

INDEPENDENT:

>Establish a working

relationship with

patient on continuity

of care

>Provide information

that patient want

and needs. Do not

provide more than

what patient can

handle

>Stress out to thesignificant others the

implications of open

and good

communication to

the patient

> Instruct significant

other to let the

patient haveadequate rest and

balanced diet

>Convey feelings of

acceptance and

understanding. Avoid

false reassurance.

> an ongoing

relationship establish

trust

>Patients who are

coping ineffectively

have reduced ability

to assimilate

information.

>Unexpressedfeelings can cause

stress

>to facilitate coping

strengths,

inadequate diet andfatigue can be a

stressor

At the end duty and

giving nursing

intervention,

patients ask

questions about

Parkinsons, obtains

help from family orfriends


12/16


Subj.Hangtod karon

wala pa gayud ko

makasabot sa sakit sa

akong bana, as

verbalized by

significant other.

Obj.

>Multiple questions

>Lack of questions

Apparent confusion

condition

Knowledge deficit

related to

uncertainty about

cause of the disease

and its treatment as

evidenced by

multiple questionsod the significant

other and confusion

over condition.

After 1-2 hours of

giving health

teachings significant

patient and other will

verbalize

understanding on

disability and specialneeds with regard to

disease process,

activity, exercise,

ambulation,

medication, diet and

elimination

INDEPENDENT

-Reinforce explanation of

disease and treatment.

Disease: has a gradual onset,

progresses gradually, has no

known cure.Treatment: therapy aimed at

relieving symptoms and

preventing complications

-Encourage independence and

avoid overprotection by

permitting patient to do things

for self: self-care, feeding,dressing, and ambulation

- Discuss with patient,

family/significant others:

Medication:

Potential side effects of

common medications

Diet:

*a high-caloric, soft diet, is

recommended

*finger food is easier for the

patient to manage

All of this

information will

promote

knowledge and

understanding

especially with

the significantother about the

disease

process.

After 1-2 hours of

giving health

teachings

significant patient

and other

verbalized

understanding on

disability andspecial needs with

regard to disease

process, activity,

exercise,

ambulation,

medication, diet

and elimination.


13/16

independently

*utensils should be within easyreach

*use blender for thick foods

*use brace for severe tremors

occurring during meals

*maintain 2000ml/day liquidintake

*offer frequent small feedings

*use straws and bibs for

excessive drooling

*instruct patient to swallow

slowly and take small bites offood

Activity:

*plan for periods

*encourage passive and active

ROM exercise to all extremities

*encourage family/significant

others to participate in physical

therapy exercises of stretching

and massaging muscle

*encourage daily ambulation

outdoors but avoidance in


14/16

extreme hot and cold weathers

*encourage patient to practicelifting feet while walking, using

a heel-to-gait, and swinging

deliberately while walking.

*Avoid sitting for long periods

*Encourage patient to dressed

daily, avoid clothing withbottoms, and shoes with laces

or snaps or Velcro

*Offer divertional activities

depending on the extent of

tremors or disability; read,

watch television and hobbies

Speech Therapy:

*Instruct patient to speak

slowly and practice reading

aloud in an exaggerated

manner

Oral Hygiene:

*Perform Q2-4h and prn (

especially if drooling ) and have

tissues accessible to patient

Elimination:


15/16

*Institute voiding measure as

needed

*Institute bladder controlled

program as needed

*Raised toilet sits with side-rail

at home

*Avoid constipation; encourage

fluids, use of natural laxatives (prune juices and rough age)

and stool softeners as needed


16/16

care plan colon

Documents