nako dito tapos di pa rin ako makagalaw masyado kase nga hirap ako. as verbalized by the client
O> Alert, conscious, coherent Afebrile Oriented to time, place and person. Poor skin turgor capillary refill after 3 seconds Muscle strength of 3/5 on upper and 2/5 on lower extremities Auscultated 5-6 borborygmic sound in each quadrant for 1 minute. Tympany heard @ each quadrant w/ grade 2 pressure ulcer at sacral area w/Oxygen via nasal cannula @ 1 lpm w/ heplock @ R metacarpal w/ suprapubic Activity intolerance secondary to underlying process as evidenced by verbal report of weakness Short Term Goal: After 8 hours of nursing intervention, patient will be able to identify negative factors affecting activity tolerance and able to eliminate or reduce their effects when possible.
Long Term Goal: After 2-3 days of nursing intervention, client will demonstrate a decrease in physiological signs of intolerance. INDEPENDENT: >Monitored for abnormal vital signs. >Assessed the muscle strength and ADL. >Note client reports of weakness, fatigue, pain, difficulty accomplishing task. >Plan care to carefully balance rest periods with activities. >Provide positive atmosphere, while acknowledging difficulty of the situation for the client. >Encouraged verbalization of feelings. >Provided comfort measures such as therapeutic touch and quiet & clean environment. DEPENDENT: >Check CBG and other laboratory values. >Administer medications as prescribed by the doctor. COLLABORATION: >Collaborate with dietician and other health care team.
>Establish a baseline data and check patients condition. >Check the functional range. >Symptoms may be result or may contribute to intolerance of activity. >To reduce fatigue
>To help in minimizing frustration and rechanneling energy
>To enhance ability to participate in activities. >To help patient to relieve anxiety, irritation and uncomfortability to the situation. >Provide comfort and safety. >Check for abnormality in the values. >To relieve any possible pain of discomfort.
>Modify the food and other health services appropriate to the pt. Short Term Goal: After 8 hours of nursing intervention, patient was able to identified negative factors affecting activity tolerance and able to eliminate or reduce their effects when possible.
Long Term Goal: After 3 days of nursing intervention, patient was able to demonstrated a decreased in physiological signs of intolerance. catheter to urine bag w/ edema on upper & lower extremities
BP: 130/70 T: 36.4 H: 107 R: 19
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION S> Masakit na ang sugat ko sa likod at tila ba hindi ko maintindihan kung kalian gagaling. as verbalized by the client O> Alert, conscious, coherent Afebrile Oriented to time, place and person. Poor skin turgor capillary refill after 3 seconds Muscle strength of 3/5 on upper and 2/5 on lower extremities Auscultated 5-6 borborygmic sound in each quadrant for 1 minute. Impaired skin integrity r/t physical immobilization as evidenced by grade 2 pressure ulcer Short Term Goal: After 8 hours of nursing intervention, patient will be able to demonstrate understanding of plan to heal skin and prevent re-injury Long Term Goal: After 2-3 days of nursing intervention, client will display timely healing of pressure sores without complication. INDEPENDENT:
> Assess site of skin impairment and determine cause
>Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether the client is experiencing changes in sensation or pain. Pay special attention to high-risk areas such as bony prominences, skinfolds, the sacrum, and heels > Monitor the client's
> To provide the basis for additional testing and evaluation to start the assessment process
>To inspect systematic & identify impending problems early
>To avoid harsh cleansing agents, hot Short Term Goal: After 8 hours of nursing intervention, patient was able to demonstrated understanding of plan to heal skin and prevent re-injury Long Term Goal: After 2-3 days of nursing intervention, client was able to displayed timely healing of pressure sores without complication. Tympany heard @ each quadrant w/ grade 2 pressure ulcer at sacral area w/Oxygen via nasal cannula @ 1 lpm w/ heplock @ R metacarpal w/ suprapubic catheter to urine bag w/ edema on upper & lower extremities
BP: 130/70 T: 36.4 H: 107 R: 19 skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing. > Monitor the client's continence status, and minimize exposure of skin impairment and other areas of moisture from incontinence, perspiration, or wound drainage. > Do not position the client on site of skin impairment. If consistent with overall client management goals, turn and position the client at least every 2 hours. Transfer the client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.
water, extreme friction or force, or cleansing too frequently
> Moisture from incontinence contributes to pressure ulcer development by macerating the skin
>To prevent further pressure ulcer on the site of impairment