“dako man mi ug baryonon diri, kanus-a man ko makauli?

” as verbalized by the
patient
S

Restlessness (consistent in changing side lying position from one side to the
other)
O Family income of - 4, 000 pesos/ month

A Anxiety related to situational crisis

SHORT TERM: at the end of 2 hours, the patient will be able to have a relief of
P anxiety.

LONG TERM: at the end of 1 day, the patient will be able to control situation
without severe signs of anxiety

A. listened attentively, allowed the patient to express feelings verbally

B. spent 10 minutes with the patient twice per shift, conveyed willingness to
listen
C. Identified and reduced as many environmental stressors as possible.
Limit visitors
I D. Taught family members in coping with patient’s anxious behavior
E. Monitored for physical responses that may indicate in the increase level
of anxiety.

E At the end of 2 hours, the patient was able to have a sense of control over the
situation
 “ kinahanglan pa ko agakon ug ayo para makabakod”

Heart rate of 80 beats per minute

Limited range of motion
O Assisted in feeding

A Impaired mobility related to body weakness.

SHORT TERM: at the end of 1 hour, the patient will demonstrate skills in
P conserving energy while carrying simple self care activities .

LONG TERM: at the end of 1 day, the patient will be able to report increase in
activity tolerance while self feeding.

A. encouraged patient to eat a diet high in protein

B. instructed patient and significant others to help alternate periods of rest
and activity
C. Monitored and recorded heart rate and blood pressure after walking.
D. Advised watcher to assist when ambulating
I

E At the end of 1 day, the patient was able to report increase in activity tolerance
 “wala na raba mi kwarta ipalit sa iya tambal” as verbalized by the watcher
S

Family income - 4,000 pesos

Socio-economic status – low class
O

Risk for compromised ineffective family coping

A

SHORT TERM: at the end of 1 hour, the family will be able to verbalize feelings
P of confidence about the current situation

LONG TERM: at the end 1day, the family will be able to identify resources
within themselves to deal with the situation

A. established rapport and acknowledged difficulty of the situation for the

family
B. discussed underlying reasons for patient’s behaviors with the family
C. reframed negative expressions into positives whenever possible
D. determined level of anxiety in the family
I E. referred to family counseling

At the end of 1 hour, the family was able to verbalized feelings of confidence
E about the current situation
 Nabalaka man kayo me amu bayrunon diri, kanusa man ko makauli?” as
S verbalized by the patient

Restlessness
Family income –P4,000
O

A Ineffective coping related to situational crisis

SHORT TERM: at the end of 1 hour, the patient will verbalize awareness of
P own coping abilities

LONG TERM: at the end of 1day, the client will show positive signs of
acceptance with her new situation in life and develop interventions with
acceptable resources.

A. noted expressions of indecision and inability to manage own activities of

daily living
I B. noted presence of positive coping skills, use of relaxation techniques
C. encouraged patient to talk about what is happening
D. provided quiet environment
E. referred to family members

At the end of 1 hour, the patient has verbalized awareness of own coping
E abilities
S
“Ga sigi ko higda, initan kayo ko sa ako likod” as verbalized by the patient.

O
Diaphoresis

A Risk for impaired skin integrity related to prolonged bed rest

P Short term: at the end of 1 hour, the client will be able to participate in the
prevention of skin breakdown

Long term: at the end of 1 day, the client will be able to maintain skin integrity

I
A. Noted areas of altered circulation
B. Encouraged position changes in bed at intervals
C. Provided frequent skin care, using mild nondetergent soap.
D. Kept bed clothes dry and kept bed free from wrinkles.
E. Provided adequate clothing or covers.

E At the end of 1 day, the client has participated in the prevention of skin care