Nsvd Case Study Scribd App

 

T A B L E O F C O N T E N T S

I. INTRODUCTION..............................................................................1II. GENERAL DATA...............................................................................2III.HISTORY OF PRESENT ILLNESS................................................22IV. PAST HEALTH HISTORY...............................................................2V. FAMILY, PERSONAL , SOCIAL AND ENVIRONMENTAL HISTORYA. MEMBERS OF THE FAMILY.....................................................4B. PERSONAL AND SOCIAL HISTORY..........................................4C. ENVIRONMENTAL HISTORY...................................................4D. HEREDO-FAMIAL HISTORY......................................................4

VI.

A. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED.........5-7B.DISCUSSION OF THE PHYSIOLOGY.................8C.SYMPTOMATOLOGY.............................................9.VII. MEDICAL MANAGEMENT........................................10A. TREATMENT AND PROCEDURES.......................10B. MEDICATIONS.....................................................10C.DIET.......................................................................10VIII. NURSING MANAGEMENT....................................11A. ACTUAL GIVEN............................................11

 

Nursing Care PlanPatient’s Name: XYAge

: 26 y/o

Diagnosis: NSVDAssessmentNursingDiagnosisInferenceGoalsInterventionsRationaleEvaluationSubjective:

“di akomakatulog kasipuro na langsakit sa katawanyungnararamdamanko”

Objective:

1hr of sleepper day PTA

30 mins of sleep perday uponadmission

frequentyawning atdaytimeduringassessment

overall bodymalaise

pain(8 out of 10)

dark circlesaround theDisturbedsleeping patternrelated to painand discomforton perineumsecondary tolabor anddeliveryBecause of the painat the perineum r/tepisioraphy, normalbody relaxation ishindered leading toprolonged period of time without sleepor sleep deprivation

References:

Wikipedia:http://en.wikipedia.org/wiki/Sleep

Short Term

After 3 hours of nursingintervention, the clientwill:

report decreasedfeeling of discomfort asmanifested byverbalizing feeling of comfort (5 out of 10)

Achieve at least 5-6hours of continuoussleep per day

Show signs of decreased yawning atdaytime

Report decreasedbody malaise

Expected OutcomeLong Term

After 3 days of nursingintervention the clientwill:

Be able toreestablish andmaintain normal sleeppattern

Independent

Position clientin a comfortableposition

Providecomfortmeasures(touch, quietenvironment,dim light, lightmusic)

Assess sleeppattern

Provide a quietand peacefulenvironmentduring sleepperiods

Encourage theclient to expressconcerns when

 To alleviatediscomfort

 To distractattention onpain, reducetension and topromotenonpharmacological painmanagement

 To providecomparativebaseline

 To help inproviding bettersleep/rest

Verbalizingconcerns maypromoterelaxation

Short Term :

After 3 hours of nursing intervention,the short term goalwas met asevidenced by:

Reported painrelief (5 out of 10)

Pt was able toachieve 6hours of continuoussleep that day

decreasedyawning atdaytime

reporteddecreasedoverall bodymalaise

Long Term

After 3 days of nursing interventionthe short term goal

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