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C. NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION
SUBECTIVE CUES:
halos apat na
oras lang ako
nakakatulog sa
isang araw dahil
ang ingay sa bahay
namin, at kapag
nagising na ko di
na ko makatulog
uletas verbalized
by the patient
OBECTIVE CUES:
-report of
difficulty falling
asleep
-increasing
irritability
-restless
-presence of
periorbital
puffiness
Disturbed sleep
pattern related to
environmental
changes as evidenced
by awakening earlier
than desired.
After 30mins of
health teaching,
the patient will
be able to
verbalize
understanding
about
therapeutic
management on
how to improve
sleep pattern
INDEPENDENT:
-Promote bedtime comfort
regimen (warm bath and
massage)
-Reduce noise and light
-Match with roommate who
has similar sleep patterns.
-Instruct relaxation measure
-Encourage position of
comfort, assist in turning
-Avoid/limit interruptions(awakening for medications)
DEPENDENT:
-Administer sedatives as
indicated.
-Helps induce sleep
-Provides atmosphere
conducive to sleep.
-Decreases likelihood that
night owl roommate may
delay clients falling asleep
or create interruptions thatcause awakening.
-Promotes a relaxing
soothing effect.
-Repositioning alters areas
of pressure and promotes
rest.
-Uninterrupted sleep ismore restful, and client may
be unable to return to sleep
when wakened.
-May be given to help client
sleep and rest.
After 30mins.
Of health
teaching, the
patient was
able to
verbalized
understanding
about
therapeutic
management
on how to
improve sleeppattern.
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ASSESSMENT NURSING
DIAGNOSIS
PLANNING NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE
CUES:
nagkasugat ako
sa noo dahil sa
pagkakabagsak
ko sa sahig as
verbalized by the
patient.
OBECTIVE CUES:
-open wound inthe forehead
above the right
eyebrow
Risk for infection
related to
inadequate primary
defenses due to
aging process (cells
degeneration)
-After 1hour of nursing
interventions and
health teachings, the
client will be able to
identify behaviors and
practices to prevent
and reduce the risk for
infection.
Independent:
-Stress and model proper
hand-washing technique to
client and caregivers.
-Maintain aseptic technique
with any procedures. Provide
routine site care/wound care,
as appropriate.
-Inspect dressings and
wound; note characteristics
of drainage.
-Encourage frequent position
changes
-Monitor vital signs.
-Reduces risk of cross-
contamination/bacterial
colonization.
-Prevents entry of
bacteria, reducing risk of
nosocomial infections.
-Early detection of
developing infection
provides opportunity for
timely intervention and
prevention of more
serious complications.
-Limits stasis of body
fluids, promotes optimal
functioning of organsystems.
-Temperature elevation
and tachycardia may
reflect developing sepsis.
-After 1hour
of nursing
interventions
and health
teachings,
the client was
able to
identify
behaviors
and practices
to preventand reduce
the risk for
infection.
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Collaborative:
-Obtain drainage specimens,
if indicated.
-Administer antibiotics, as
indicated.
-Grams stain, culture, andsensitivity testing is useful
in identifying causative
organism and choice of
therapy.
-Wide-spectrum
antibiotics may be used
prophylactically, or
antibiotic therapy may be
geared toward specific
organisms.
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ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
SUBECTIVE CUES:
namamalikaskas
(flaky skin) yung
balat ko lalo na
saking mga binti
as verbalized by
the patient
OBECTIVE CUES:
-Dry skin
-Observed
scratching herscabs
-Skin flakes on
the patients bed
linen
Risk for Impaired skin
integrity related to dry
skin and behaviors
that may lead to skin
integrity impairment
as evidenced by
scratching of scabs
After 1hour of
nursing
intervention the
patient and the
significant
others will be
able to verbalize
understanding
of individual
factors that
contribute to
possibility ofskin integrity
impairment and
takes steps to
correct the
situation
-Establish rapport
-Monitor vital signs.
-Note age and sex
-Assess mood, abilities, and
personal styles.
-Provide health teachings
regarding the importance of
maintaining an intact and
moist skin.
-Teach the significant othersto give the client a balance,
and nutritious food especially
foods rich in Iron and vitamin
C
-Instruct the significant others
to give multivitamins to the
client
-To gain the client and
significant others trust.
-To obtain data for
comparison.
-to evaluate degree/source
of risk inherent in the
individual situation.
-To evaluate patients
attitude, this may contributeto skin breakdown.
-To increase the significant
othersknowledge thus,
prevention of skin
breakdown is realized and
taken into consideration by
the significant other.
-To improve clients immunesystem.
-To pharmacologically
improve clientsimmune
system
-After 1hour of
nursing
intervention
the client and
the significant
others was able
to verbalized
understanding
of individual
factors that
contribute to
possibility ofskin integrity
impairment
and takes steps
to correct the
situation.
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