ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC BASIS

PLANNING

INTERVENTIONS
Short-term: Independent: 1. Assessed the clients activity to bathe self via direct Observation using physical Performance tests for ADLs. 2. Developed a bathing care plan based on the clients own history of bathing practices that addresses skin needs, client response to bathing, and equipment needs. 3. Individualized bathing by Identifying function of bath (e.g., odor, urine removal), Frequency required to achieve function, and best bathingform (e.g., towel bathing, tub, shower) to meet client preferences, preserve client dignity, make bathing a soothing experience, and reduce client aggression. 4. Taught use of adaptive bathing equipment and follow up in home. 5. Ensured bathing assistance preserves client dignity through conveyance of honor and recognition of deservedness of respect and esteem of all persons regardless of their dependency and infirmity. 6. Provided privacy: have only caregiver providing bathing Assistance encouraged a trafficfree bathing area, And post privacy signs. 7. Kept the client warmly covered. 8. Enhanced communication during bathing. Allow the client to participate as able in bathing. Smile and provide praise for Accomplishments in a relaxed manner. 9. Inspected skin condition during bathing. 10. Encouraged caregiver to use unhurried, causing touch.

RATIONALE
Independent: 1. Observation of bathing performed in an atypical bathing setting may result in false date for which use of a physical performance test compensates to provide more accurate ability data. 2. Bathing is a healing rite and should be a comforting experience that concentrates on the different needs, rather than being a routinely scheduled task. 3. Individualized bathing produces a more positive bathing experience and preserves client dignity. 4. Adaptive devices extend the clients reach, increases speed and safety, and decrease exertion and reduce caregiver burden. 5. Needing assistance with bathing, being hospitalized, and having pain, were among the most significant issues fracturing a sense of the terminally ill clients dignity. 6. The clientperceives less privacy if more than one caregiver participates or if bathing takes place in a central bathing area in a high-traffic location that allows staff to enter freely during care. 7. Clients especially elderly clients, who are prone to hypothermia, may experience Evaporative cooling during and after bathing, which produces an unpleasant cold sensation. 8. Improved communication Decreases aggression during bathing and individualizes care. 9. Observation of skin allows detection of skin problems. Towel bathing facilitates inspection of skin. 10. The basic human need of touch offers reassurance and comfort.

Subjective: Nahihirapa n ako kumilos lalo na sa pagligo, pagkain as verbalized by the patient. Objective: Inability to feed self independently Inability to dress self independently Inability to bathe and groom self independently Inability to perform toileting tasks independently Inability to ambulate independently

Self-Care Deficit in bathing/ hygiene,dressi ng/grooming, feeding and toileting RT

Due to limitations in the individuals ability to ambulate, he is prevented from performing ADLs that allow her to manage her hygiene such as bathroom privileges, bathing, clothing oneself.

Short-term goal: After 6 hours of nursing interventions, the patient will be able to: 1. Remain free of body odor and maintained intact skin. 2. Bathe with assistance of caregiver as needed and report sense of dignity is maintained. 3. State satisfaction with ability to use adaptive devices to bathe. 4. Use methods to bathe safely with minimal difficulty.

ASSESSMENT
Subjective Bahala na Lola nia sa kanya (baby) magalaga, as verbalized by the mother. Hindi kase marunong magpalit ng damit ng baby, exclaimed by the father. Objective NSD G1P1

NURSING DIAGNOSIS
Health seeking behaviors r/t needs of a normal newborn

SCIENTIFIC BASIS
First time parents are usually in period of adjustment after postpartum to assume their roles as parents & the needs of their newborn child. Their lifestyle, activities & environment needs to be altered in order to accommodate the new member of their family.

PLANNING
The parents will express desires to change lifestyle, activities & environment to achieve the optimum health of their newborn. participate in planning for alterations in environment, lifestyle & activities. seek health resources to help in educating themselves with the proper care for newborn

INTERVENTIONS
Independent Health teaching on newborn care was given. Schedule of care was discussed between the parents. Advise on the newborns safety was noted. Follow-up examinations after discharge for the newborn & mother were scheduled. Dependent Appointment & visit for a first newborn assessment usually 2 to 6 weeks after delivery.

RATIONALE
In some cases especially that of the 1st time parents, they have questions & doubts on how to care for their newborn; through such interaction these can all be cleared up & issues will be settled. This is to ensure consistency with regards to the care they will be giving to the newborn. This is to strengthen their commitment in taking the role as parents. Clinical visit for the newborns assessment is Very important. This is the beginning of the health program of the child that will keep the childs wellness. Aside from newborn care, family planning methods is discussed during these appointments.

EVALUATION
Parents have altered their home & lifestyle to accommodate the newborn; they uttered with assurance their ability to care for their newborn.

ASSESSMENT
Subjective
Ayoko kumain ng walang lasa na pagkain, as verbalized.

NURSING DIAGNOSIS
Impaired adjustment r/t health status requiring change in lifestyle

SCIENTIFIC BASIS
Inability to modify lifestyle in a manner consistent with a change in status. The objective of nursing care for hypertensive patients focuses on lowering and controlling the blood pressure without adverse affects and without undue cost. To achieve these goals, the nurse must support and teach the patient to adhere to the treatment regimenby implementing necessary lifestyle changes and taking medications as prescribed.

PLANNING
After 3 days of nursing intervention, there will be an increase interest and participation on the demonstration of selfcare and will initiate lifestyle changes that will permit adaptation to present medical situation.

INTERVENTIONS
Independent
Vital signs monitored and recorded. BP monitored regularly. Instructed and emphasized necessary care and lifestyle changes that will enhance her recovery. Planned necessary care and assistance in ADLs with the parents. Emphasized the importance of adequate rest in relation to BP elevation. Emphasized the importance of adherence to medical management such as medications.

RATIONALE For baseline comparison. This will promote trust and will on the patient to adhere to such activities that will enhance fast recover. Planning with the parents will add more cooperation in the part of the patient. This will lower the patients BP.

EVALUATION
After 4 days of nursing intervention, the goal is met through participation and demonstration of lifestyle changes

Objective

c pale to pinkish lips & conjunctiva weak looking c fair appetite, selective c food preference V/S taken as follows: T = 36.7 C P = 76bpm R = 24cpm BP =130/100 mmHg

Hypertension needs medications to maintain the BP in its normal range.