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C.

NURSING CARE PLAN


ASSESSMENT SUBECTIVE CUES: halos apat na oras lang ako nakakatulog sa isang araw dahil ang ingay sa bahay namin, at kapag nagising na ko di na ko makatulog ulet as verbalized by the patient OBECTIVE CUES: -report of difficulty falling asleep -increasing irritability -restless -presence of periorbital puffiness NURSING DIAGNOSIS PLANNING Disturbed sleep pattern related to environmental changes as evidenced by awakening earlier than desired. After 30mins of health teaching, the patient will be able to verbalize understanding about therapeutic management on how to improve sleep pattern NURSING INTERVENTION RATIONALE EVALUATION After 30mins. Of health teaching, the patient was able to verbalized understanding about therapeutic management on how to improve sleep pattern.

INDEPENDENT: -Promote bedtime comfort -Helps induce sleep regimen (warm bath and massage) -Reduce noise and light -Provides atmosphere conducive to sleep.

-Match with roommate who -Decreases likelihood that has similar sleep patterns. night owl roommate may delay clients falling asleep or create interruptions that cause awakening. -Instruct relaxation measure -Promotes a soothing effect. relaxing

-Encourage position comfort, assist in turning

of -Repositioning alters areas of pressure and promotes rest.

-Avoid/limit interruptions -Uninterrupted sleep is (awakening for medications) more restful, and client may be unable to return to sleep when wakened. DEPENDENT: -Administer indicated.

sedatives

as -May be given to help client sleep and rest.

ASSESSMENT

NURSING DIAGNOSIS Risk for infection related to inadequate primary defenses due to aging process (cells degeneration)

PLANNING

NURSING INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE CUES: nagkasugat ako sa noo dahil sa pagkakabagsak ko sa sahig as verbalized by the patient. OBECTIVE CUES: -open wound in the forehead above the right eyebrow

-After 1hour of nursing interventions and health teachings, the client will be able to identify behaviors and practices to prevent and reduce the risk for infection.

Independent: -Stress and model proper -Reduces risk of crosshand-washing technique to contamination/bacterial client and caregivers. colonization. -Maintain aseptic technique -Prevents entry of with any procedures. Provide bacteria, reducing risk of routine site care/wound care, nosocomial infections. as appropriate. -Inspect dressings and -Early detection of wound; note characteristics developing infection of drainage. provides opportunity for timely intervention and prevention of more serious complications. -Limits stasis of body -Encourage frequent position fluids, promotes optimal functioning of organ changes systems. -Temperature elevation and tachycardia may reflect developing sepsis.

-After 1hour of nursing interventions and health teachings, the client was able to identify behaviors and practices to prevent and reduce the risk for infection.

-Monitor vital signs.

Collaborative: -Grams stain, culture, and -Obtain drainage specimens, sensitivity testing is useful if indicated. in identifying causative organism and choice of therapy.

-Wide-spectrum -Administer antibiotics, as antibiotics may be used indicated. prophylactically, or antibiotic therapy may be geared toward specific organisms.

ASSESSMENT SUBECTIVE CUES: namamalikaskas (flaky skin) yung balat ko lalo na saking mga binti as verbalized by the patient OBECTIVE CUES: -Dry skin -Observed scratching her scabs -Skin flakes on the patients bed linen

NURSING DIAGNOSIS Risk for Impaired skin integrity related to dry skin and behaviors that may lead to skin integrity impairment as evidenced by scratching of scabs

PLANNING After 1hour of nursing intervention the patient and the significant others will be able to verbalize understanding of individual factors that contribute to possibility of skin integrity impairment and takes steps to correct the situation

NURSING INTERVENTIONS -Establish rapport

RATIONALE -To gain the client and significant others trust.

EVALUATION

-Monitor vital signs.

-Note age and sex

-Assess mood, abilities, and personal styles.

-Provide health teachings regarding the importance of maintaining an intact and moist skin.

-After 1hour of nursing intervention -To obtain data for the client and comparison. the significant others was able -to evaluate degree/source to verbalized of risk inherent in the understanding individual situation. of individual factors that -To evaluate patients contribute to attitude, this may contribute possibility of to skin breakdown. skin integrity impairment -To increase the significant and takes steps others knowledge thus, to correct the prevention of skin situation. breakdown is realized and taken into consideration by the significant other. -To improve clients immune system.

-Teach the significant others to give the client a balance, and nutritious food especially foods rich in Iron and vitamin C -Instruct the significant others to give multivitamins to the client

-To pharmacologically improve clients immune system

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