Assessment Subjective: Mejo hindi ko kaya gumalaw pa as verbalized by the client.

. Objective: Inability to prepare food Inability of selfbathing Inability of selfdressing self-toilet deficit Vital Signs: CRRR Temp.BP-

Nursing Diagnosis Self-care deficit related to weakness, pain and impaired transfer mobility.

Planning Short term: After 2 hours of nursing intervention, the patient will be able to: Identify individual areas of weakness and needs. Long Term: After 4 days of nursing intervention, the patient will be able to: Verbalize knowledge of healthcare practices Demonstrate techniques to meet self-care needs.

Intervention Promote clients participation in problem identification and desired goals and decision making. Plan time for listening to the clients feelings and concerns. Practice and promote shortterm goal setting and achievement. Provide for communication among those who are involved in caring for the client. Establish contractual partnership with the client. Assist with necessary adaptations to accomplish ADLs. Begin with familiar, easily

Rationale Enhances commitment to plan, optimizing outcomes and supporting recovery and health promotion. To discover barriers to participation in regimen and to work on problem solutions. To recognize that todays success is as important as any long-term goal, accepting ability to do one thing at a time. Enhances coordination and continuity of care. Indicated for motivation. To encourage the client and

Evaluation After 4 days of nursing intervention, the patient is able to: Identify individual areas of weakness and needs. Verbalize knowledge of healthcare practices. Demonstrate techniques to meet self-care needs.

accomplished tasks. Review program periodically to accommodate changes in clients ability. Review safety concerns. Modify surroundings.

build on successes.

Assists client to adhere to plan of care to fullest extent. To reduce risk for injury and promote successful functioning.

Assessment Subjective: Masaki tang catheter ko as verbalized by the client. Objective: Patient is on catheter Patient is on post-operative period Presence of dressing on head part VS: CRRRTemp.BP-

Nursing Diagnosis Risk for Infection related to Inadequate primary defenses and pharmaceutical agents.

Planning Short term: After 4 hours of nursing intervention, the patient will be able to: Verbalize understanding of individual causative factors. Identify interventions to prevent or reduce risk of infection. Long term: After 4 days of nursing intervention, the patient will be able to: Demonstrate techniques to

Intervention Stress proper hand hygiene by all caregivers between therapies. Monitor clients visitors and caregivers for respiratory illnesses. Offer masks and tissues to visitors who are coughing or sneezing. Choose proper vascular access device based on anticipated treatment duration and solution or medication to be infused and best available asceptic

Rationale A first-lined defense against healthcareassociated infections. To limit exposures, thus reduce crosscontamination.

Evaluation After 4 days of nursing intervention, the patient is able to: Verbalize understanding of individual causative factors. Identify interventions to prevent or reduce risk of infection. Demonstrate techniques to promote safety environment. Achieve timely wound healings.

To reduce potential for catheter-related blood-stream infections.

promote safety environment. Achieve timely wound healings.

insertion techniques. Cleanse insertion sites per facility protocol with appropriate solutions. Encourage early ambulation, soughing and position changes.

Maintain adequate hydration and catheterization. Provide regular urinary catheter and perineal care. Administer and monitor medication regimen. Emphasize necessity of taking antivirals or antibiotics, as directed.

For mobilization of respiratory secretions and prevention of aspiration or respiratory infection. To avoid bladder distention and urinary stasis. Reduce risk of ascending urinary tract infection. To determine effectiveness of therapy or presence of side effects. Premature discontinuation of treatment when client begins to feel well may result in return of infection and potentiate drug resistant strains.