CUES

NURSING DIAGNOSIS Self-Care Deficit: bathing/ hygiene, dressing/ grooming, feeding, toileting

SCIENTIFIC EXPLANATION

OBJECTIVES (PLANNING)

NURSING INTERVENTIONS > promote pt./ SO participation in problem identification and decision making

RATIONALE

EXPECTED OUTCOME SHORT TERM >After 4 hours of NI, the pt. shall have been able to verbalize knowledge of health care practices.

S> O > pt. may manifest inability to: - prepare food for ingestion; open containers - handle utensils; get food onto utensil safely; bring food from a receptacle to mouth - wash body or body parts - get in and out of the bathroom/ tub - dry body > pt. may manifest inability to

Self-care deficit is the SHORT TERM impaired ability to >After 4 hours perform feeding, of NI, the pt. will bathing or hygiene, be able to dressing and verbalize grooming, or knowledge of toileting activities for health care oneself [on a practices. temporary, permanent, or progressing basis]. LONG TERM > After 2 days of NI, the pt. will demonstrate techniques/ lifestyle changes to meet selfcare needs

> enhances commitment to plan, optimizing outcomes

> plan time for > to discover listening to the pt./ barriers to SO participation in regimen > review safety concerns > review/ modify program periodically to accommodate changes in clients abilities > assist with necessary adaptations to accomplish ADLs; begin with familiar, easily accomplished > to reduce risk of injury > assists client to adhere to plan of care to fullest extent

LONG TERM > After 2 days of NI, the pt. shall have demonstrated techniques/ lifestyle changes to meet self-care needs

> to encourage pt. and build on successes

put on or take off necessary items of clothing; fasten locks/ zippers; put on socks/ shoes >pt. may manifest inability to get to toilet/ commode; carry out proper toilet hygiene

tasks > review instructions from other members of the health care team and provide written copy

> provides clarification, reinforcement, and periodic review by pt./ caregivers

H Y P E R T H E R M I A ASSESSMENT S> NURSING DIAGNOSIS Hyperthermia SCIENTIFIC OBJECTIVE EXPLANATION Fever is not an Short term: illness and it is an O> the patient important part of the bodys After 4 INTERVENTIONS Monitor record VS RATIONALE EXPECTED OUTCOME obtain Short term: After the NI, the pts To pts

and To

baseline data

hours of NI, the pts Assess general condition

manifested:

defense against infection

determine temperature shall decreased have to

temperature will be able to decrease to

current status

normal range Determine precipitating Identifying the underlying cause essential recovery is to Long term: After the NI, the pt shall

Hyperthermia Pain Infection Albumin trace on urinalysis

Antigens

or

normal range

microorganisims causes inflammation and the release of which substance After 2 days Long term:

factors

pyrogens of NI, the pt is a will be able to that be free of complications Control environmental

have been free of

Removing

complications

source of heat and

 Vs: 39.8 20 cpm 86 bpm 110/70 mmHg

induces fever

and core

maintain

tempereature

can begin the maintained cooling process core and core temperature reduce temperature within normal range.

temperature within normal range

This decreases warmth Remove excess clothing and covers increases evaporative cooling and

To Provide TSB temp

decrease y

conduction

These measure help promote Provide cooling

additional cooling mechanisms like the use of fan and local ice packs To like

Administer analgesics

promote in core

decrease body

Paracetamol as ordered

temperature

A C U T E

P A I N EXPECTED OUTCOME Short term: Goal Met. After 2-3 hours of

ASSESSMENT S>

SCIENTIFIC NURSING EXPLANATIO DIAGNOSIS N Ascariasis in the hepatobiliary tract can cause acute cholecystitis, acute cholangitis, obstructive

OBJECTIVE Short term:

INTERVENTIONS

RATIONALE

Masakit Acute Pain

yung sa may bandang balakang ko. Sa likod chaka lalo na kapag umiihi

O> patient

the

jaundice, acute pancreatitis and hepatic

manifested: Observed evidence of pain Grimaces,

liver abscess. After gaining entry from the ampulary

Document location, Helps evaluate the site duration, intensity, of obstruction and and radiation. Note progress. Flank pain After 2-3 hours of nonverbal signs such may be suggestive that nursing as elevated BP, pulse, presence of renal restlessness, moaning, stones are already in interventions, and guarding the kidney area. patient will be able behaviors. This will provide timely to verbalize non administration of analgesia pharmacologic and alerts care givers to Explain cause of pain the possibility of passing means of pain and importance of stone / developing notifying health care complications. management and providers of the identify positions changes in pain occurrence and that may Promotes relaxation, characteristics. contribute to reduces muscle tension, and enhances muscle relaxation coping. Provide comfort Long term: measures and encourage deep Relieves muscle breathing exercises. After 3-4 days of tension and may

nursing interventions, patient was able to verbalize non pharmacologic means of pain

management and identify positions that contribute may to

muscle relaxation

easily distracted Positionin g relieve pain Diaphores is Narrowed attention span to

orifice the worms can

nursing interventions,

reduce reflex spasms

freely move in patient will be able Apply warm compress Pain may worsen in to back and out of the to report a marked supine position, vigorous hydration biliary tree reduction in pain promotes passing of and they can sensation. stone, prevents urinary stasis, and aids in cause Encourage with prevention of further frequent ambulation abdominal stone formation as indicated and pain in the increased fluid intake patient. Note reports of increased / persistent Complete obstruction abdominal pain of ureter may cause perforation and extravasation of urine into perirenal space. This may represent an acute surgical emergency. Administer medications as ordered: Narcotics, NSAIDS, Ibuprofen This is to reduce renal colic and promote muscle relaxation

Long term: Goal Met. After 3-4 days of

nursing interventions, patient was able to report a

marked reduction in pain sensation as evidenced by a relaxed appearance appropriate resting and and

sleeping patterns.

Risk for injury Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Interventions Rationale Expected Outcomes

S> O> patient manifested: >left-sided body weakness >inability to perform ADLs >patient is being assisted by SOs in doing ADLs patient may manifest: > inability to adapt to environmental conditions >frequent muscle spasms

Risk for injury

The risk for injury continues throughout recovery from hepatobiliary ascariasis. It may also extend into the home environment, where patients attempt to perform former activities, such as walking, cooking or dressing. Factors that increase the risk for injury include decreased level of consciousness, weakness, flaccidity, spasticity, impulsive behavior, altered thought processes and

Short term: After 5 hours of nursing interventions, the patient will demonstrate behaviors to reduce risk factors and to protect self from injury.

> Establish rapport

> To establish nurse-patient relationship.

Short term:

> Monitor vital signs. > Note age and sex of the patient.

Long term: After 4 days of nursing interventions, the patient will remain free from injury as evidenced by an absence of abrasions, burns or falls.

> Evaluate developmental level, decisionmaking ability, level of cognition and competence.

> Assess mood, coping capabilities and personality styles like temperament, aggression and impulsive behavior.

The patient shall have >To establish demonstrated baseline data. behaviors to reduce risk >Elderly persons factors and to are at greater protect self risk of injury. from injury after 5 hours of > To determine nursing the technique to interventions. use in educating the patient on Long term: how to reduce or eliminate risk The patient factors. shall have remained free > These may from injury as result in evidenced by an carelessness or absence of increased risk abrasions, burns taking without or falls after 4 consideration of days of nursing consequences. interventions. > May enhance disregard for own or others

motor, visual and spatialperceptual impairments.

safety. > Evaluate patients response to violence > To determine in surroundings. the severity of body weakness and to be able > Assess muscle to perform strength, gross and appropriate fine motor interventions. coordination. > To promote safe physical environment and individual safety. > Identify interventions and safety devices such > Impulsive as asking for behaviors may assistance in increase the risk performing ADLs. of the patient to injury. > Encourage use of techniques to > To enhance reduce stress and self-esteem and vent emotions such sense of worth. as anger and hostility. > Encourage participation in self> to make the patient be self-

help programs such as assertiveness training and positive self-image. > Discuss to patient/SO importance of selfmonitoring of conditions/emotions that can contribute to occurrence of injury. > Encourage patient to prevent doing things beyond what her body can perform. > Instruct SO to assist client in performing her activities of daily living. > Instruct SO to understand the patient especially when she is in distress.

reliant and be responsible of her own safety.

> To reduce the occurrences of injury.

> To reduce risk for injury.

> The understanding and support of people who are close to the patient may increase the wellness of the patient.