82202039-NCP-WARD10

8/13/2019 82202039-NCP-WARD10

1/7

RLE 002Cebu Normal University

College of NursingCebu City

Mission-Vision: Care Using Knowledge and Compassion

Name of Student:__________________________________________ Clients Initials:___________________________________________ Stressor Classification: ( lease c!ec"#$ge:______%ender: _____Civ il Status:________&eligion:_______ ______ !ysiological (body structure and functions#$llergies: ________________________________________________ ______ syc!ological (mental ' rocesses and emotion#

iet:_____________________________________________________ ______ Socio-cultural (relations!i 's) social e*'ectat ions#ate of $dmission:________________________________________ ______ S'iritual (influence of s'iritual beliefs#iagnosis+Im'ression:_____________________________________ ______ evelo'mental (develo'mental 'rocesses over t!e

lifes'an#

NURSING DIAGNOSIS NURSING GOALS NURSING OU CO!E$ssessment iagnosis Mutual lanning

(%oal attainable ,it!in t!es!ift#

Interventions(,it! &ationale Source#

$ctual .valuation

S"#$e%&i'e(

Kapo) i*li+o,*li+o,-as 'er#ali.ed/

O#$e%&i'e(/received sitting onbed0a,a"e0conscious0co!erent/c 1

$ctivity Intolerance r+t$fter 2 !ours of nursingintervention) 'atient ,illuse identifiedtec!ni3ues to en!anceactivity tolerance4

&IM$&5 IN6.&V.N6I7NSromo&i'e(

I/ romote 'ro'er and balanced nutrition4&/ 6o 'rovide a good nutritional status4I/ romote ade3uate e*ercise) rest and slee'4&/ 6o 'rovide a good sense of ,ell-being4I/ romote !ealt!y lifestyle4&/ 6o 'rovide a good sense of ,ell-being4I/ romote good and 'ro'er !ygiene4

&/ 6o 'rovide a good sense of ,ell-being4S/ oenges) et4 $l4 Nurses oc"et %uide4

re'en&i'e(

I/8ave a regular c!ec"-u' ,it! t!e doctor4&/ 6o 'rovide a regular u'date on over-all,ell being4

6!eory-based ( Betty Neuman #

NURSING CARE LAN

$ssessment 9 'oints %oals 'oints Interventions ; 'oints

8/13/2019 82202039-NCP-WARD10

2/7

/generali>ed ,ea"nessnoted/slo,ed movementobserved/delayed res'onsenoted/'allor observed/does not tal" to S7and ot!ers t!at muc!/slo,-voiced observed

/fre3uently on bednoted

+eore&i%al #asis(

A%&i'i&) In&oleran%e is&+e ins"33i%ien&p+)siologi%al orps)%+ologi%al energ)&o end"re or

%omple&e re4"ired ordesired dail)a%&i'i&ies/

6.&6I$&5IN6.&V.N6I7NSRe+a#ili&a&i'e

I/&efer to classes orsu''ort grou's) asa''ro'riate4&/6o 'rovide additionalinformation anden!ance com'liance tot!era'eutic regimenS/ oenges) et4 $4l4

I/ Com'lete immuni>ations4&/ 6o avoid certain diseases or increaseimmunity on certain diseases4I/Clean environment4&/ 6o avoid environment-induced diseases4I/ $void smo"ing and alco!ol4&/ 6o avoid lifestyle-induced com'lications4

S.C7N $&5 IN6.&V.N6I7NSC"ra&i'e

I/$ssess level of activity&/6o 'rovide a baseline for c!angesI/.ncourage verbali>ation of feelings&/6o "no, ,!at client truly feelsI/6eac! diversional activities: readingne,s'a'er+boo"&/6o 'rovide activities graduallyI/ romote comfort measure&/6o 'rovide comfortI/6eac! energy conservationtec!ni3ues&/6o conserve energy to more

im'ortant activitiesI/$ssist in $ ?s&/6o 'rovide !el' ,!ile 'romotinginde'endence as ,ell4I/$d@ust activities&/6o 'revent overe*ertionI/ rovide 'ositive atmos'!ere&/6o encourage 'atient continually

5i#liograp+)( Doenges- e&/ Al/ N"rse6s o%,e& G"ide/ pp/78*9:

8/13/2019 82202039-NCP-WARD10

3/7






lifes'an#NURSING DIAGNOSIS NURSING GOALS NURSING OU CO!E

$ssessment iagnosis Mutual lanning(%oal attainable ,it!in t!e

s!ift#


$ctual .valuation

S"#$e%&i'e(

A?uya a"ong la,as)B asverbali>ed4

O#$e%&i'e(/received sitting onbed0a,a"e0conscious0

atigue r+t$fter 2 !ours of nursingintervention) 'atient ,illre'ort an im'rovedsense of energy4


I/ romote 'ro'er and balanced nutrition4&/ 6o 'rovide a good nutritional status4I/ romote ade3uate e*ercise) rest and slee'4&/ 6o 'rovide a good sense of ,ell-being4I/ romote !ealt!y lifestyle4&/ 6o 'rovide a good sense of ,ell-being4I/ romote good and 'ro'er !ygiene4&/ 6o 'rovide a good sense of ,ell-being4S/ oenges) et4 $l4 Nurses oc"et %uide4

re'en&i'e(I/8ave a regular c!ec"-u' ,it! t!e doctor4&/ 6o 'rovide a regular u'date on over-all


NURSING CARE LAN


8/13/2019 82202039-NCP-WARD10

4/7

co!erent/c 1

/generali>ed ,ea"nessnoted/slo,ed movementobserved/delayed res'onsenoted

/'allor observed/does not tal" to S7and ot!ers t!at muc!/slo,-voiced observed/fre3uently on bednoted/disinterested insurroundings noted/com'romisedconcentration

+eore&i%al #asis(

;a&ig"e is &+eo'erw+elmings"s&ained sense o3e

8/13/2019 82202039-NCP-WARD10

5/7






lifes'an#

NURSING DIAGNOSIS NURSING GOALS NURSING OU CO!E$ssessment iagnosis Mutual lanning

(%oal attainable ,it!in t!es!ift#


$ctual .valuation

S"#$e%&i'e(

No sub@ective cues4

O#$e%&i'e(

&is" for falls r+tdecreased bodilystrengt!

$fter 2 !ours of nursingintervention) 'atient ,illbe free of in@ury4


I/ romote 'ro'er and balanced nutrition4&/ 6o 'rovide a good nutritional status4I/ romote ade3uate e*ercise) rest and slee'4

&/ 6o 'rovide a good sense of ,ell-being4I/ romote !ealt!y lifestyle4&/ 6o 'rovide a good sense of ,ell-being4I/ romote good and 'ro'er !ygiene4&/ 6o 'rovide a good sense of ,ell-being4S/ oenges) et4 $l4 Nurses oc"et %uide4

re'en&i'e(I/ 8ave a regular c!ec"-u' ,it! t!e doctor4


NURSING CARE LAN


8/13/2019 82202039-NCP-WARD10

6/7

/received sitting onbed0a,a"e0conscious0co!erent/c 1

/generali>ed ,ea"nessnoted/slo,ed movementobserved

/delayed res'onsenoted/'allor observed/does not tal" to S7and ot!ers t!at muc!/slo,-voiced observed/fre3uently on bednoted/disinterested insurroundings noted/com'romisedconcentration

/absence of side-railsnoted/S7 fre3uently out oft!e room and+orslee'ing/absence of safetymeasures noted

+eore&i%al #asis(

Ris, 3or 3alls is &+ein%reaseds"s%ep&i#ili&) &o3alling &+a& ma)%a"se p+)si%al +arm/

6.&6I$&5IN6.&V.N6I7NSRe+a#ili&a&i'e

I/&efer to classes or

su''ort grou's) asa''ro'riate4&/6o 'rovide additionalinformation anden!ance com'liance tot!era'eutic regimenS/ oenges) et4 $4l4

&/ 6o 'rovide a regular u'date on over-all,ell being4I/ Com'lete immuni>ations4&/ 6o avoid certain diseases or increaseimmunity on certain diseases4I/Clean environment4&/ 6o avoid environment-induced diseases4I/ $void smo"ing and alco!ol4&/ 6o avoid lifestyle-induced com'lications4

S.C7N $&5 IN6.&V.N6I7NSC"ra&i'eI/$ssess muscle strengt!&/6o 'rovide basis for interventionI/ ractice client safety: use of siderails&/6o "ee' 'atient safeI/$dvise S7 to ,atc! t!e 'atient at alltimes) or to !ave anot!er S7 ats!ifting times&/6o !ave somebody ,atc! over'atientI/Ma"e environment more safe bydrying ,et floors or "ee'ing a,ay!armful ob@ects or obstacles&/6o ma"e 'atient free of in@uryI/$ssist in $ ?s&/6o increase 'atient safetyI

8/13/2019 82202039-NCP-WARD10

7/7

5i#liograp+)( Doenges- e&/ Al/ N"rse6s o%,e& G"ide/pp:::*::9

82202039-NCP-WARD10

Documents

Transcript of 82202039-NCP-WARD10