NURSING PROBLEM PRIORITIZATION A.

Prioritizing identified nursing problem

Date identified January 24, 2013

Cues Blood Chemistry Result/ lithium intake

Problem Nursing Diagnosis Risk for Unstable Blood Glucose due to mental health status as evidenced by increase triglycerides and cholesterol with Risk for infection due to inadequate primary defenses specifically broken skin Impaired religiosity related to the use of religion to manipulate Chronic sorrow related to experiences of having chronic illness specifically mental illness

January 24, 2013

Presence of open wound on her scalp

January 24, 2013

January 25, 2013

Tells stories that are related to her religious beliefs and happenings Cries every time the conversation was about how her past experiences

Justification The result of her blood chemistry shows an increase specifically on her cholesterol level with ____ and triglycerides with a level of _____. The client have an open wound because of too much scratching of the scalp due to dandruff and having lice and nits. The client tells that she have a marital relation to Christ The client tell stories about how her sister/family thinks of her mental illness that she denies to have.

B. Nursing care plan Risk for Infection due to inadequate primary defenses specifically broken skin Assessment Subjective Cues: May sugat ako sa ulo dahil sa dandruff ang gamit kasi namin sa ulo ay perla,kaya kinakamot ko. Diagnosis Risk for Infection due to inadequate primary defenses specifically broken skin Planning Intervention Short Term Goal: After 20-25 minutes Dependent of nursing - Provide intervention the dimensional client will be able to activities. know on how to - State the lessen itchiness. possible complication Long Term Goal: , if, not well After 1-2 hours of manage e.g. nursing intervention infection. the client will be - Provide able to decreased comfort the risk for severe measures( infection, e.g. touch) Independent - Give antibiotics as prescribed by the doctor. Rationale Evaluation

To distract attention.

Objective Cues: -Presence of open wound at the scalp -presence of dandruff -presence of lice and nits

To treat bacteria that causes infection

Impaired Skin Integrity related to dirty environment secondary to presence of insects in the ward as manifested by numerous & scattered wounds in the legs. ASSESSMENT Subjective: ang dami ko ng kati sa binti ang dumi kasi dun sa loob puro dura, tae tsaka suka Objective: > numerous & scattered wounds in the legs >some wounds are healed and some are new DIAGNOSIS Impaired Skin Integrity related to dirty environment secondary to presence of insects in the ward as manifested by numerous & scattered wounds in the legs. PLANNING LONG TERM GOAL: After 45days of nursing intervention, clients wound will be decreased. SHORT TERM GOAL: 1 day Display timely healing of wounds w/o complications. 1 day Maintain optimal nutrition/ physical well-being 1day- Verbalize feelings of increased self-esteem and ability to manage situation. INTERVENTION DEPENDENT: > inspect skin on a daily basis, describing wound characteristics and changes observed > keep the area clean/dry to prevent infection RATIONALE > to monitor the changes on clients wound EVALUATION LONG TERM GOAL: GOAL METAfter 4-5 days of nursing intervention, clients wound will be decreased. SHORT TERM GOAL: - Display timely healing of wounds w/o complications. - Maintain optimal nutrition/ physical wellbeing. - Verbalize feelings of increased selfesteem and ability to manage situation. [ ]Goal met [ ]Goal partially

> to assist bodys natural process of repair

>assist the client in understanding & following medical regimen. Dependent:

> Enhances commitment to plan, optimizing outcomes.

Give ointment as To treat bacteria prescribed by the doctor

met [ Adult failure to thrive related to depression ASSESSMENT NURSING DIAGNOSIS Adult failure to thrive related to depression. NURSING INTERVENTION LONG TERM INDEPENDENT GOAL > assist with After 7 days of treatment of nursing intervention, underlying client will be able to medical/psychiatric cope with the reality. condition. SHORT TERM GOAL After 2-3 days of nursing intervention client will be able to somehow can make decisions on her own. > assist client to develop goals for dealing with life/illness situation > monitor clients behavior and assist in use of stress management techniques PLANNING RATIONALE EVALUATION ]Goal unmet

Subjective: hindi ko alam bakit dinala ako dito basta sinabi nila sira daw ang ulo ako hindi ko pa alam ang gagawin basta gusto ko na makalabas at maayos ang buhay ko Objective: >cognitive decline: demonstrated difficulty in reasoning and decision making.

LONG TERM >that could GOAL positively influence After 7 days of current situation nursing (e.g. addressing intervention, client depression) was able to cope with the reality. >to promote [ ]Goal met commitment to goals [ ]Goal partially and plan, met maximizing [ ]Goal unmet outcomes > to avoid fatigue that may further impair cognitive abilities SHORT TERM GOAL After 2-3 days of nursing intervention client was able to somehow can make decisions on her own. [ ]Goal met [ ]Goal partially met [ ]Goal unmet