NURSING CARE PLAN

Patients Name: Bubbles

Age: 60 yrs. old

Chief Complaint: Weakness, Pale Skin, Dyspnea, Fatigue

Ward: Med ward alley

Date & Time

CUES

J u' l y 1, 2 0 1 1 8:30a m

Sujective cues: Dile mayo akong paminaw gang dle kaau ko kalihok ug higda human putolputol akong tulog. Objective cues: Weak Restlessness Anxious Pale lips Dry oral mucosa Dry skin Easy to get tired Vital Signs: BP: 90/60 Temp: 38.9 PR: 83 RR: 26

N E E D A C T I V I T Y E X E R C I S E

NURSING DIAGNOSIS

OBJECTIVE/GOAL

NURSING INTERVENTIONS

EVALUATION

Fatigue related to Poor oxygen supply as manifested by weakness, pallor & Lab results

Within 4 hours of nursing intervention the client will be able to: 1. Report improved sense of energy. 2. Indentify basis of fatigue and individual areas of control. 3. Perform ADLs and participate in desired activities at level of ability. 4. Participate in recommended treatment program.

1. Monitor of Vital Signs every 4 hours. Monitoring assesses baseline data. 2. Evaluate aspect of learned helplessness that may be manifested by give up. Can perpetuate a cycle of fatigue, impaired functioning , and increased anxiety and fatigue . 3 Establish realistic activity goals like move around with client. Enhances commitment to promoting optimal outcomes. 4 Plan care to allow individually adequate rest periods. Schedule activities for periods when client has the most energy. To gain energy. 5 Provide environments conductive to relief of fatigue. To provide quite environment

Goal partially met after 4 hours of nursing intervention the client was able to understand and participate some of the health teachings that I had said, as evidence by verbalization salamat narse ah nakapahulay ko ug maau basig gamay ra ingana diay na cge buhaton nako na.

Rationale: An overwhelmin g sustained sense of exhaustion and decrease capacity for physical and P mental work A at usual level. T T Source: E Nurses R Pocket Guide N 12 Edition by: Marilynn E. Doenges.

6 Provide diversional activities. Avoid overstimulation/ under-stimulation (cognitive and sensory). Impaired concentration can limit ability to blok cocmpeting stimuli/distractions 8 Instruct client in ways to monitor responses to activity and significant signs/symptoms like if is theres a dizziness do not walk immediately That indicate the need to alter activity level. 9 Provide supplement oxygen as ordered by the doctor. Presence of anemia/hypoxemia reduces oxygen available for cellular uptake and contributes to fatigue. 10 Assist client to identify appropriate coping behaviors. Promotes sense of control and improves self-esteem

Date & Time

CUES

J u' l y 1, 2 0 1 1 8:30p m

Subjective cues: Init man akong paminaw gang uy human ginatugnaw ko Objective cues: Weak Shivering Restless Eyes are always Tired Temp: 38.9 C

N E E D N U T R I T I O N M E T A B O L I C P A T T E R N

NURSING DIAGNOSI S Hyperthermi a related to infection and increased metabolic rate; illness or trauma Rationale: Body temperature elevated above normal range Source: Nurses Pocket Guide 10th edition

OBJECTIVE/GOAL

NURSING INTERVENTIONS

EVALUATION

Within 2 hours of 1. Monitor of Vital Signs every 4 nursing intervention the hours. client will be able to: Monitoring assesses baseline data. -Maintain core temperature within normal range of 36.537.5 C -To Identify underlying cause -Demonstrate behavior to monitor and promote normothermia 2 Tepid Sponge Bath done To lower down the temperature to its normal range 3 Maintain bed rest To reduce metabolic demands/oxygen consumption 4 Instructed the client to use the blanket to cover both upper and lower extremities To minimize shivering 5 Discuss importance of adequate fluid intake To prevent dehydration

Goal Met after 2 hours of nursing intervention the clients temperature decreases from 38.9 C to 37.4 C as evidenced by verbalization of the client. Medyo mas maayo na akong paminaw gang dle na kaau ko ginatugnaw

Date & Time

J u' l y 1, 2 0 1 1 8:30p m

N E E D H Subjective E cues: Narse ka nang A naga luya man L T ko ui as H verbalized by the client P E Objective R cues: C Vital Signs: E BP: 90/60 P Temp: 38.9 T PR: 83 I RR: 26 O N Positive H Grimaced E A L T H

CUES

NURSING DIAGNOSI S Risk for infection related to increased temperature

OBJECTIVE/GOAL

NURSING INTERVENTIONS

EVALUATION

Within 4 hours of 1. Monitor of Vital Signs every 4 nursing intervention the hours. client will be able to: Monitoring assesses baseline data. 1 Verbalized understanding of individual causative/risk factors. 2 Identify interventions to prevent/reduce risk of infection. 3 Demonstrate techniques, lifestyle changes to promote safe environment. 2. Stress proper hand washing techniques by all caregivers between therapies/clients. A first-line defense against nosocomial infections/crosscontamination. 3. Provide for isolation as indicated Reduces risk of cross-contamination. 4. Encourage early ambulation, deep breathing, coughing, position change For mobilization of respiratory secretions. 5. Tepid Sponge Bath applied To regulate the temperature 6. Maintain adequate hydration, stand/sit to void, and catheterize if necessary To avoid bladder distention.

Goal Met after 4 hours of nursing intervention the watcher was able to understand the importance of health teachings I had gave and applied to the client appropriately.

Rationale: Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. M Infections A occur when N an organism

A G E M E N T P A T T E R N

(e.g., bacterium, virus, fungus, or other parasite) invades a susceptible host. Breaks in the integument, the bodys first line of defense, and/or the mucous membranes allow invasion by pathogens. Source: http://nursing careplan.blog spot.com/200 9/02/ncpnursingdiagnosisrisk-for.html

Date & Tim e J u' l y 1, 2 0 1 1 1:00 pm

CUES

Subjective cues: Gang mahadlok ko ba kay basig mahulog ko siya kama ma trauma ko ba kay sa iyang dugo. As verbalized by the watcher Objective cues: Add resistance to side rails

N E E D H E A L T H P E R C E P TI O N H E A L T H M A N A

NURSING DIAGNOSIS

OBJECTIVE/GOAL

NURSING INTERVENTIONS

EVALUATION

Risk for fall Within 4 hours of related to no side nursing intervention rails in bed the client will be able to: Rationale: 1 Verbalized understanding of Increased individual factors that susceptibility to contribute to possibility falling that may of injury and take steps cause physical to correct situation(s). harm. Source: Nurses Pocket Guide 10th edition 2.Modify environment as indicated to enchance safety 3 Be free of injury

1 Note age and sex children, elderly persons, and men are greater risk.

2 Assess mood, coping abilities, personality styles( e.g. temperament, aggression, impulsive behavior, level of slef esteem) That may result in careless/increased risk-taking without consideration of maau unta gang kung naay consequences\ higdaanan ato bah para mu kampante nako. 3 Evaluate individuals response to violence in surroundings May enhance disregard for own/others safety. 4 Identify interventions /safety devices to promote safe physical environment and individual safety. 5 Position extremities To facilitate periodic evaluation of circulation, nerve pressure, and body alignment, especially when moving table attachments.

Goal partially Met after 4 hours of nursing intervention the watcher was not able to learned all of the health teachings but still the watcher perceived the client to be free of injury, as evidence by verbalization

G E M E N T P A T T E R N

6 Check peripheral pulsesand skin color/temperature periodically To monitor circulation. 7 Reposition slowly in sitting and walking To prevent severe drop in BP, dizziness 8 Assist with therapies/nursing actions including skin care measures, early mobilization To promote skin and tissue integrity.

Date & Tim e J u' l y 1, 2 0 1 1 8:30 am

CUES

Subjective cues: Stress ko narse kay daghan tau nagaagi-agi mao na murag luya xa as verbalized by the watcher. Objective cues: Weakness dying activity Restless Eyes are always sleepy or tired Lab exam results

N E E D A c t i v i t y a n d e x e r c i s e p a t t

NURSING DIAGNOSIS

OBJECTIVE/GOAL

NURSING INTERVENTIONS

EVALUATION

Activity Intolerance related to generalized weakness Rationale: Insufficient physiological or psychological energy to endure or complete required or desired daily activities Source: Nurses Pocket Guide 10th edition

Within 4 hours of nursing intervention the client will be able to: 1 Identify negative factors affecting activity tolerance and elimination

1 Evaluate current limitations/degree of deficit in light of usual status Provides comparative baseline 2.Assess emotional/psychological factors affecting the current situation stress and /or depression may be increasing the effects of an illness, or depression might be the result of forced into activity. 3 Adjust activities To prevent overexertion 4 Plan care with rest periods between activities To reduce fatigue 5 Promote comfort measures and provide for relief of pain Enhance ability to participate in activities. 6 Give client information that provides evidence of daily/weekly progress To sustain motivation

Goal Met after 4 hours of nursing intervention the watcher was able to demonstrate decrease in physiological signs which was evidenced by verbalization of watcher. medyo dile na kaau ko ma luya gang salamat ah

2 participate willingly in necessary/desired activities. 3 Demonstrate a decrease in physiological signs of intolerance

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7 Assist client learning and demonstrating appropriate safety measures To prevent injuries 8 Review expectations of client /SO(s) providers To establish individual goals 9 Encourage client to maintain positive attitude to enhance sense of well-being