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C. NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION

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

uletas verbalized

by the patient

OBECTIVE CUES:

-report of

difficulty falling

asleep

-increasing

irritability

-restless

-presence of

periorbital

puffiness

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

INDEPENDENT:

-Promote bedtime comfort

regimen (warm bath and

massage)

-Reduce noise and light

-Match with roommate who

has similar sleep patterns.

-Instruct relaxation measure

-Encourage position of

comfort, assist in turning

-Avoid/limit interruptions(awakening for medications)

DEPENDENT:

-Administer sedatives as

indicated.

-Helps induce sleep

-Provides atmosphere

conducive to sleep.

-Decreases likelihood that

night owl roommate may

delay clients falling asleep

or create interruptions thatcause awakening.

-Promotes a relaxing

soothing effect.

-Repositioning alters areas

of pressure and promotes

rest.

-Uninterrupted sleep ismore restful, and client may

be unable to return to sleep

when wakened.

-May be given to help client

sleep and rest.

After 30mins.

Of health

teaching, the

patient was

able to

verbalized

understanding

about

therapeutic

management

on how to

improve sleeppattern.

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ASSESSMENT NURSING

DIAGNOSIS

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 inthe forehead

above the right

eyebrow

Risk for infection

related to

inadequate primary

defenses due to

aging process (cells

degeneration)

-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

hand-washing technique to

client and caregivers.

-Maintain aseptic technique

with any procedures. Provide

routine site care/wound care,

as appropriate.

-Inspect dressings and

wound; note characteristics

of drainage.

-Encourage frequent position

changes

-Monitor vital signs.

-Reduces risk of cross-

contamination/bacterial

colonization.

-Prevents entry of

bacteria, reducing risk of

nosocomial infections.

-Early detection of

developing infection

provides opportunity for

timely intervention and

prevention of more

serious complications.

-Limits stasis of body

fluids, promotes optimal

functioning of organsystems.

-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 preventand reduce

the risk for

infection.

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Collaborative:

-Obtain drainage specimens,

if indicated.

-Administer antibiotics, as

indicated.

-Grams stain, culture, andsensitivity testing is useful

in identifying causative

organism and choice of

therapy.

-Wide-spectrum

antibiotics may be used

prophylactically, or

antibiotic therapy may be

geared toward specific

organisms.

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ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

SUBECTIVE CUES:

namamalikaskas

(flaky skin) yung

balat ko lalo na

saking mga binti

as verbalized by

the patient

OBECTIVE CUES:

-Dry skin

-Observed

scratching herscabs

-Skin flakes on

the patients bed

linen

Risk for Impaired skin

integrity related to dry

skin and behaviors

that may lead to skin

integrity impairment

as evidenced by

scratching of scabs

After 1hour of

nursing

intervention the

patient and the

significant

others will be

able to verbalize

understanding

of individual

factors that

contribute to

possibility ofskin integrity

impairment and

takes steps to

correct the

situation

-Establish rapport

-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.

-Teach the significant othersto 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 gain the client and

significant others trust.

-To obtain data for

comparison.

-to evaluate degree/source

of risk inherent in the

individual situation.

-To evaluate patients

attitude, this may contributeto skin breakdown.

-To increase the significant

othersknowledge thus,

prevention of skin

breakdown is realized and

taken into consideration by

the significant other.

-To improve clients immunesystem.

-To pharmacologically

improve clientsimmune

system

-After 1hour of

nursing

intervention

the client and

the significant

others was able

to verbalized

understanding

of individual

factors that

contribute to

possibility ofskin integrity

impairment

and takes steps

to correct the

situation.

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