Assessment

Subjective:
anong oras na?
as verbalized by
the client
Objective:
>Frequent asking
of time
>Frequent
looking at the
clock
>Inability to
recall
>Irritable
>Restless

Nursing
Diagnosis
Impaired memory
related to
degenerative
brain disease as
manifested by
frequent asking
of time and
inability to recall

Planning
Within 8 hours of
nursing care the
client will show
decrease anxiety
on remembering
events

Intervention

Rationale

>established
rapport

>to establish
trust and for the
client to feel
comfortable

>reoriented
client on time
and place when
client show
confusion

>to decrease
clients anxiety
and confusion

>if client feel

delusional
acknowledged
feeling and
reoriented to
reality
>consistently
identified self
and addressed
the client by
name at each
meeting
>administered
prescribed
medications

>do not attempt

to challenge the
content of the
delusion it will
create tension for
the client
>to give client
sense of
accomplishment

> to prevent
further damage
or complications
on the clients

Evalution
after 8 hours of
nursing care the
client showed
decreased
anxiety on
remembering
events

condition
>collaborated to
other
professionals

>it is a big help

to have others to
supervise the
client with
dementia to give
the most
effective care

Assessment
Subjective:
hindi kaya
maligo ni isko
magisa as
verbalized by the
helper

Nursing
Diagnosis
Self care deficit
related to
neuromuscular
impairment as
manifested by
clients paralysis

Planning

Intervention

Rationale

Evalution

Within 1hr of
nursing care the
client will have
proper hygiene
as evidenced by:
>proper
grooming

> assessed
clients needs

> to know what

procedure the
nurse should do

>identified
degree of
impairment and
function level
(cannot extend
right arm and
unable to walk)

>to assess
degree of
disability, to
allow client to do
things he can on
his own

after 1hr of
nursing care the
client have
proper hygiene
as evidenced by:
>proper
grooming

Objective:
(+) impaired
speech

>clean hair and

finger nails
>brushed teeth

(+) paralysis on
the right side of
the body

>absence of bad
body odor

>clean hair and

finger nails
>brushed teeth

>prepared
morning
care/hygiene
care:

- unable to walk
a) bathed client
with warm water
(shampoo hair,
scrub groin and
armpit area)

>absence of bad
body odor
> geriatric
patient are more
sensitive to
temperature
>groin and
armpits are prone
to bacteria

b) brushed teeth

> to avoid tooth

decays and
toothaches

c) shaved facial
hairs (beard and

> facial hair can

cause itchyness

mustache)
d) applied
deodorant, lotion,
powder and
cologne
e) collaborate
among those who
are involve in
caring

ASSESSMENT
S: Nangangati

DIAGNOSIS
Risk for impaired

PLANNING
After 3 hours of

INTERVENTIONS
>Maintained

>to further
eliminate bad
odor, to
moisturize skin
> to enhance
care and
continuity of care

RATIONALE
>To decrease

EVALUATION
After 3 hours of

ang balat ko, di

ko maiwasan
kamutin as
verbalized by the
client
O:
(+)dry, flaky skin
(+)inflammation
decreased skin
turgor
-irritability

tissue integrity r/t

physical
immobilization as
evidenced by dry,
flaky skin

nursing care, the

patient will
verbalize feelings
of increased selfesteem and will
participate in
preventive
measures and
management
program.

meticulous skin
hygiene, using
mild soap and
lotion
>Massaged bony
prominences and
used proper
positioning,
turning, lifting
and transferring
technique
>Changed
position in bed or
chair on a regular
schedule
>Emphasized
importance of
adequate fluid
intake

irritable itching

>To prevent
friction

>To prevent
pressure sores

>For hydration
of skin

>To reduce risk

of dermal injury
when severe
itching is present

>Kept nails short

>To enhance
circulation

>Encouraged

nursing care, the

patient has
verbalized
feelings of
increased selfesteem and
participated in
preventive
measures and
management
program.

continuation of
regular exercise
program
(assistive)