NURSING CARE PLAN ASSESSMENT SUBJECTIVE: Naiistorbo ang tulog ko dahil sa mga nurse po pabalik balik as verbalized by the

patient Objective: Yawning Slowed reaction Restlessn ess Irritable DIAGNOSIS Sleep Deprivations related to interruptions for therapeutics, monitoring and other generated awakening Background Knowledge Prolonged periods of time without sleep [Sustained natural, periodic suspensions If relative consciousness] ( Nurses Pocket Guide 10th Edition, pp.498502) PLANNING Within 3-hour of nursing Interventions, Patient will achieve optimal amount of sleep as evidenced by rested appearance and improvement in sleep pattern INTERVENTION Observe and obtain feedback from patient regarding usual bedtime, routines, number of hours of sleep and environmental needs Do possible care without waking the patient, and do care when the patient still awake Explain necessity of disturbances for monitoring VS care when hospitalized Encourage wearing cover, drinking warm milk, and sleeping at the same time each nigh RATIONALE To determine usual sleep pattern and provide appropriate intervention To avoid disturbances during sleep and to maximize sleeping process To have an understandi ng and to minimize complaints To Enhance ability to fall asleep EVALUATION Patient achieved optimal amount of sleep as evidenced by rested appearance and improvement in sleep pattern

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ASSESS MENT Subjective: Nahihirapan kong tumayo as verbalized by the patient Objective: Limited range of motion Limited ability to perform gross and fine movemen t Slow movemen t Teary eyes Difficulty turning

DIAGNOSIS Impaired Physical mobility related to spinal affectation of C5 Background Knowledge Defined as the state in which an individual has a limitation in independent, purposeful physical movement extremities ( Nurses Pocket Guide 11th Edition, pp.457-461)

PLANNING Within 3-hour of Nursing Interventions, Patient will verbalize understanding of the situation individual treatment regimen and safety measures

INTERVENTION Determine the diagnosis that contributes to immobility Determine the degree of immobility in relation to suggested scale Determine presence of complications related to Potts disease Assist patient reposition self on a regular schedule

RATIONALE To identify contributing Factors To assess functional mobility To assess complication To promote optimum level of function and prevent complication To maintain position and also to reduce risk for pressure ulcer

EVALUATION Within 3-hour of Nursing Interventions, Patient verbalized understanding of the situation individual treatment regimen and safety measures

Support affected body part

Encourage adequate fluids and nutritious foods

To promote wellbeing and maximizes energy production Evaluation Within 3 hour of Nursing Interventions, The patient Verbalized about Knowledge of Healthcare Practices

Assessment Objective: Inability to handle utensils and get food Inability to wash body or body parts Inability to carry out proper toilet hygiene

Diagnosis Self-Care Deficit Related to musculoskeletal impairment as evidence by inability to carry out proper toilet hygiene, etc. Background Knowledge Impaired ability to perform feeding, bathing/hygiene, dressing or grooming and toileting activities for oneself [on a temporary, permanent, or progressing basis] ( Nurses Pocket Guide 10th

Planning Within 3 hour of Nursing Interventions, The patient will Verbalize about Knowledge of Healthcare Practices

Intervention Establish rapport Provide Health Teaching on patient regarding the proper way of effective toilet hygiene

Rationale To have trust and cooperati on To provide adequate knowledg e

Assist patient in feeding Arrange for assistive devices as necessary Assist/support family with alternative placement as

To meet nutritional status To help/ assist the patient to move To enhance likelihood of finding individuall

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necessary

y appropriat e situation to meet clients needs