C.

NURSING PROBLEM PRIORITIZATION

NURSING PRIORITY No. 1

DATE IDENTIFIED May 6, 2013

CUES P.A.: Dry Lips and Bucccal Mucosa Signs of dehydration

PROBLEM / NURSING DIAGNOSIS

JUSTIFICATION

May 6, 2013

3 oras lang tulog ko. Pag sandali lang tulog parang pagod parin as stated by the client. Score of 3 in sleep quality; 10 is the highest Makakalimutin na ako as verbalized by the client.

Maslows Hierarchy of Human Deficient Fluid Volume related Needs; Physiological Needs to decreased fluid intake prior to (Water) cataract surgery as manifested - Number 1 priority, proper by dry lips and buccal mucosa hydration would promote homeostasis thus helping in the recovery of the patient after the surgery and will promote wellbeing Maslows Hierarchy of Human Sleep Deprivation related to Needs; Physiological Needs (Sleep) aging-related sleep stage shifts - 2nd priority, sleep deprivation among elderly poses increased risk for falls and other accidents due to clumsiness and decreased mental allertness Impaired Memory related to Aging Maslows Hierarchy of Human Needs; Physiological Needs; (Homeostasis) -3rd priority, Aging naturally degrades the neurons of the brain causing impaired cognitive functioning; forgetfulness poses a risk for accidents and injuries and should be addressed.

May 6, 2013

E. NURSING CARE PLAN I ASSESSMENT NURSING DIAGNOSIS Deficient Fluid Volume related to decreased fluid intake prior to cataract surgery as manifested by dry lips and buccal mucosa GOALS INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: N/A OBJECTIVE : Dry Lips and Bucccal Mucosa Signs of dehydration

SHORT TERM GOALS: Within 15 minutes of nursing intervention client will: Verbalize the importance of hydration to the body, especially among elderly people. LONG TERM GOAL: Within a week of nursing intervention client is expected to: Demonstrate signs of good hydration

INDEPENDENT: Discuss the importance of maintaining hydration. Note client preferences and instruct significant others to provide beverages and foods with high fluid content. Instruct the significant others to use mild soap and provide optimal skin care with suitable emollients. Correct information facilitates compliance Providing variety of choices increases compliance

Short Term goals: Within the 15 minutes that nursing intervention was implemented, expected goals have been: Met

To maintain skin integrity and prevent excessive dryness

As evidenced by client performed the following goals within the preset time: Verbalizes the importance of hydration to the body, especially among elderly people. Significant others agreed to follow the advised therapeutic regimen.

LONG TERM GOAL: Within a week of nursing intervention, expected goals have been: Unmet As evidenced by : Long Term Goals have a much longer timeframe and our client did not return for his follow-up check-up.

NURSING CARE PLAN II ASSESSMENT NURSING DIAGNOSIS SUBJECTIVE: 3 oras lang tulog ko. Pag sandali lang tulog parang pagod parin as stated by the client. Score of 3 in sleep quality; 10 is the highest OBJECTIVE: Drooping of eyelids Sleep Deprivation related to agingrelated sleep stage shifts

GOALS

INTERVENTION

RATIONALE

EVALUATION

SHORT TERM GOALS: Within 15 minutes of nursing intervention client will: Verbalize new relaxation techniques that would promote good sleep. LONG TERM GOALS: Within a week of nursing intervention client is expected to: Report improvement in Sleep/Rest Pattern.

INDEPENDENT: Recommend bedtime snack like warm milk and crackers or bread 15 to 30 minutes before retiring. Promote adequate physical exercise activity during day.

Short Term goals: Sense of fullness and Within the 15 minutes that nursing intervention was satiety promotes implemented, expected sleep goals have been: Enhances expenditure of energy/release of tension so that client feels ready for sleep or rest Soothing music reduces stimulation so client can relax Met

Recommend quiet activities such as listening to soothing music in the evening.

As evidenced by client performed the following goals within the preset time: Client verbalizes new relaxation techniques that would promote good sleep. LONG TERM GOAL: Within a week of nursing intervention, expected goals have been: Unmet As evidenced by :

Long Term Goals have a much longer timeframe and our client did not return for his follow-up check-up.

NURSING CARE PLAN III ASSESSMENT NURSING DIAGNOSIS SUBJECTIVE: Makakalimutin na ako as verbalized by the client. OBJECTIVE: N/A Impaired Memory related to Aging

GOALS

INTERVENTION

RATIONALE

EVALUATION

SHORT TERM GOALS: Within 15 minutes of nursing intervention client will: Verbalize methods to help in remembering essential things when possible. LONG TERM GOALS: Within a week of nursing intervention client is expected to: Verbalize satisfaction in remembering things using the instructed techniques.

INDEPENDENT: Implement appropriate memory retraining techniques (e.g. keeping calendars, writing lists) Emphasize importance of pacing learning activities and getting sufficient rest. Instruct the significant others to facilitate relaxation techniques like playing soothing music. For ease of remembering and safety

Short Term goals: Within the 15 minutes that nursing intervention was implemented, expected goals have been: To avoid fatigue that may further impair cognitive abilities Met

As evidenced by client performed the following goals within the preset time: Client verbalizes methods to help in remembering essential things when possible. To reduce frustration and enhance enjoyment of life LONG TERM GOAL: Within a week of nursing intervention, expected goals have been: Unmet As evidenced by :

Long Term Goals have a much longer timeframe and our client did not return for his follow-up check-up.