ACTUAL NCP ASSESSMENT DIAGNOSIS PLANNING Subjective: Disturbed sleep pattern related Within my 8 hour span of care, Dili

kaayo ko katulog kay to unfamiliar sleep my patient will be able to nanibago ko sa akong palibot, surroundings as verbalized by the patient. - Report improved sleep. - Report increased sense of well-being and feeling rested. Objective: -drooping eyes - weakness - lethargic INTERVENTION EVALUATION

Establish rapport with the Within my 8 hour span of care, patient to gain my patient was able to cooperation. Monitor V/S - Report improved sleep. Note environmental factors, such as unfamiliar - Report increased sense of well-being and feeling or uncomfortable room rested as evidenced by these factors can reduce Medyo nakatulog nako, clients ability to rest and as verbalized by the sleep at a time when more patient. rest is needed. Observe for physical signs of fatigue (drooping eyes). GOAL PARTIALLY MET! Adjust ambient lighting to maintain daytime light and night time dark. Encourage patient to watch face, hands and brush teeth before sleeping. Straighten the bed sheets, change clothes to promote physical comfort. Minimize sleep disturbing factors (reduce talking). Perform monitoring and
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care activities without waking client whenever possible. Allows for longer periods of uninterrupted sleep.

ACTUAL NCP ASSESSMENT Subjective: Dili kayo ko kalihok kay sakit akong tiil, bug-at, as verbalized by the patient. DIAGNOSIS Activity intolerance related to pain of the feet PLANNING Within my 8 hour span of care, my patient will be able to Objective: Limited movement 2 out of 10 pain scale Report measurable increase in activity tolerance Participate willingly in necessary/desired activities INTERVENTION Establish rapport with the patient to gain cooperation. Monitor V/S Ascertain ability to stand and move about and degree of assistance necessary or use of equipment to determine current status and needs associated with participation in needed/desired activities. Adjust activities to prevent overexertion. Reduce intensity level or discontinue activities that cause undesired physiological changes. Elevate the feet of the patient to provide comfort. Encourage client to eat a balanced diet. Assist client in walking or moving. Encourage client to have EVALUATION Within my 8 hour span of care, my patient was be able to Report measurable increase in activity tolerance, as evidenced by Makalakaw nako ug hinay2 ug kung nay mualalay, as verbalized by the patient. Participate willingly in necessary/desired activities.

GOAL PARTIALLY MET!

a positive attitude towards the situation.

ACTUAL NCP ASSESSMENT Subjective: Sakit akong tiil, as verbalized by the patient. DIAGNOSIS Acute pain related to physical factor PLANNING Within my 8 hour span of care, my patient will be able to Report pain is controlled. Verbalize nonpharmacological methods that provide relief. Demonstrate use of relaxation skills and diversional activities, as indicated for individual situation. INTERVENTION Establish rapport with the patient to gain cooperation. Monitor V/S Assess for referred pain, as appropriate to help determine possibility of underlying condition or organ dysfunction requiring treatment. Provide comfort measures (touch, repositioning), quiet environment and calm activities to promote nonpharmacological pain management. Instruct and encourage use of relaxation techniques. Encourage diversional activities. Encourage adequate rest periods to prevent fatigue. EVALUATION Within my 8 hour span of care, my patient was able to Report pain is controlled. Verbalize nonpharmacological methods that provide relief as evidenced by Kabalo nako karon kung unsaon pagpawala sa sakit maski gamay, as verbalized by the patient. Demonstrate use of relaxation skills and diversional activities, as indicated for individual situation. GOAL PARTIALLY MET!

Objective: - Sleep disturbance - Positioning to avoid pain

POTENTIAL NCP ASSESSMENT DIAGNOSIS PLANNING Within my 8 hour span of care, my patient will able to Identify interventions to prevent or reduce risk of confusion. INTERVENTION EVALUATION

Objective: Risk for confusion related to fluctuation in sleep-wake - Inattention cycle. - Weakness - Drooping eyes - Lack of interest in activties

Establish rapport with the Within my 8 hour span of care, my patient was able to patient to gain cooperation. - Identify interventions to Monitor V/S prevent or reduce risk of Evaluate sleep and rest confusion as evidenced by status, noting sleep Maam, kabalo nako kung deprivation. unsay dapat buhaton aron Maintain calm dili ko mapuyat, as environment and eliminate verbalized by the patient. extraneous noise or other stimuli to prevent GOAL PARTIALLY MET! overstimulation. Promote early ambulation activities to enhance wellbeing and reduce effects of prolonged bed rest or inactivity. Provide for safety needs (ambulating with assistance). Provide undisturbed rest periods (reduce talking). Prepare the bed before sleeping.

POTENTIAL NCP ASSESSMENT Objective: - Weakness - Decreased ability to move DIAGNOSIS Risk for falls related to foot problems. PLANNING Within my 8 hour span of care, my patient will able to Verbalize understanding of individual risk factors that contribute to possibility of falls. Modify environment as indicated to enhance safety. INTERVENTION EVALUATION

Establish rapport with the Within my 8 hour span of care, my patient was able to patient to gain cooperation. - Verbalize understanding Monitor V/S of individual risk factors Observe for individuals that contribute to health status, noticing possibility of falls. factors that might affect safety, such as chronic or - Modify environment as indicated to enhance debilitating conditions, use safety of multiple medications, recent trauma. Practice client safety. GOAL PARTIALLY MET! Demonstrate behaviors for client to emulate. Assist client with activities. Raise side rails as indicated. Encourage the need for and sources of supervision.