C.

NURSING CARE PLAN ASSESSMENT Subjective: Objective: -hair with lice -dirty fingers noted -skin rashes -unpleasant odor noted NURSING DIAGNOSIS Self-care deficit in bathing/hygien e r/t perceptual or cognitive impairment PLANNING After 3 hours of nursing interventions, the patient will be able to demonstrate techniques/ lifestyle changes to meet self-care needs NURSING INTERVENTION 1. Assess the clients ability to bathe self through direct observation (in usual bathing setting only) noting their specific deficits and their causes 2. Plan activities during bathing 3. Instruct pt. to select bath time when he or she is rested or unhurried 4. Encourage independence, but intervene when pt. cannot perform 5. Use consistent routines & allow adequate time for patients to complete tasks RATIONALE 1. Use of observation of function provides complementary assessment data for goal and intervention planning. 2. Energy conservation increases activity tolerance & promotes self-care. 3. Hurrying may result in accidents & the energy required for these activities may be substantial 4. An appropriate level of assistive care can prevent injury with activities without causing frustration. 5. This helps patient organize & carry out self-care skills. EVALUATION After 3 hours of nursing interventions, the patient was able to demonstrate techniques/ lifestyle changes to meet self-care needs. The goal was: _ _ MET __ PARTIALLY MET __ NOT MET

6. The need for 6. Provide privacy privacy is during bathing/ dressing fundamental for most as appropriate patients 7. Assist pt. with care fingernail s & toenails as required 8. Provide supervisions for each activity until patient performs skill competently & in safe in independent care; reevaluate regularly to be certain that the patient is maintaining skill level and remains safe in environment 9. Provide positive reinforcement for every accomplishment made 7. Patients may require nail care to prevent injury to feet during nail trimming or because special implements are required to cut nails. 8. The patients ability to perform selfcare measures may change often over time and will need to be asses regularly. 9. Positive reinforcement enhances selfesteem & encourages repetition of desirable behaviors.

ASSESSMENT SUBJECTIVE: Hindi ako nakatulog ng maayos kanina. as verbalized by the client. OBJECTIVE: restlessness noted dark circles under eyes yawning

DIAGNOSIS Disturbed Sleep Pattern related to hyperactivity

PLANNING After an Hour, Patient will be able to report feeling rested improvement in sleep/rest pattern.

INTERVENTION INDEPENDENT Assess past patterns of sleep in normal environment: amount, bedtime rituals, depth, length, positions, aids, and interfering agents. Instruct patient to follow as consistent a daily schedule for retiring and arising as possible.

RATIONALE

EVALUATION

After an hour of Sleep patterns Nursing Interventions, the are unique to each individual. patient was able to report the techniques in her sleeping pattern. This promotes regulation of the circadian rhythm, and reduces the energy required for adaptation to changes. To promote sleep

Recommend an environment conducive to sleep or rest (e.g., quiet, comfortable temperature, ventilation, darkness, closed door).

Often, the patients

Document nursing or caregiver observations of sleeping and wakeful behaviors. Record number of sleep hours. Note physical (e.g., noise, pain or discomfort, urinary frequency) and/or psychological (e.g., fear, anxiety) circumstances that interrupt sleep. Increase daytime physical activities as indicated.

perception of the problem may differ from objective evaluation.

This reduces stress and promotes sleep. Different drugs are prescribed depending on whether the patient has trouble falling asleep or staying asleep

COLLABORATIVE Administer sedatives as ordered.

ASSESSMENT SUBJECTIVE: baka hindi na ako mahal ng asawa ko, hindi na kasi nya ako sinusundo ditto. As verbalized by the client. OBJECTIVE: Decreased sleep Lack of initiative or involvement in care Teary eyes when talking about her significant others Sad while happy

DIAGNOSIS Hopelessness related to long term stress and abandonment

PLANNING After an hour of nursing interventions the client will be able to recognize and verbalize her own feelings.

INTERVENTION Note behaviors indicative of hopelessness. Determine suicidal thoughts and if the client has a plan. Help client begin to develop coping mechanism that can be learn and used effectively to counter act hopelessness.

RATIONALE To assess level of hopelessne ss. To identify causative/ contributin g factors. To assist client to identify feelings and to begin to cope with problems that perceived by the client. To assist client to identify feelings and to begin to

EVALUATION After an hour of nursing interventions the client can now identify and use of coping mechanisms to counteract feelings of hopelessness.

Encouraged client to verbalized and explore feelings and

perceptions(e.g., anger, helplessness, confusion, grief)

cope with problems that perceived by the client. To promote wellness.

Provide positive feedback for actions taken to deal with and understands feelings of hopelessness Encourage structured and controlled increase in physical activity..

To enhance sense of well-being.