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8/12/2019 Case Pres Ncp Final
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VII. Nursing Care Plans
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: nahihirapan
Safe care deficit:hygiene related to
After hours ofnursing
! identify degree ofindividual impairment
!to identify thee"tent of the
After hours ofnursing
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:nars panu #olilinisin ng maayosang ari #o$
Ris# for infectionrelated toinsufficient#no%ledge toavoid e"posure topathogens
After hours ofnursingintervention& thepatient verbali'eunderstanding ofris# factors
!teach ris# factors foroccurrence of infection(e") s#in integrity&environmental e"posure*!Proper hand %ashing!cleanse incision sitesdaily
!to have proper#no%ledge aboutris# factors ininfection!to avoid crosscontamination!to prevent buildup of pathogens
After hours ofnursingintervention& thepatient hasverbali'edunderstanding ofris# factors
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:$Sumasa#it sa#it unginoperahan sa#in$as verbali'ed bythe patient+bjective:!,rimace facialreaction!pain scale of -
Pain related tosurgical incision
After hours ofnursingintervention& thepatient %ill sho%decrease or reliefof pain)
!monitor vital signs&including pain scale
!provide ade.uate restperiods and assist in acomfortable position!encourage deepbreathing e"ercises!administer analgesics asordered
!establishbaseline in orderto determineneededinterventions!promotesrecovery! relieves muscleand emotionaltension! to relieve pain
After hours ofnursingintervention& thepatient has sho%nrelief of pain)
8/12/2019 Case Pres Ncp Final
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a#ong linisanang ari #o
pain& discomfort intervention& thepatient %ill be ableto perform safecare activities
%ithin level of o%n
ability
!allo% patient to performactivities to the fullest ofhis ability and assist asneeded
!provide positivereinforcement for tas#ssuccessfully and/orindependentlyaccomplished
patient0sstrength!to ma#e thepatientindependent of
their o%n s#illsand assist ifneeded)!forencouragementof the patient toparticipate in theactivities
intervention& thepatient is able toperform safe careactivities
Assessment D
iagnosis Planning Intervention Rationale Evaluation
Subjective:
madalas a#o
matuyuan ng
lalamunan
ngayon at tuyo
lagi ang bibig
#o$
+bjective:
!Decrease
urine output!1hirst
(drin#ing
eagerly*
!Dry lips and
s#in
!Poor s#in
turgor
2luid volume
Deficit related
to dehydration
as manifested
by diarrhea
After hours
of 3ursing
Interventions&
the patient
%ill sho%
improved
hydration
status
!monitor I/+
!instruct to
increase oral
fluid inta#e
!advice to
avoid caffeine&
tea& grape and
fruit juice
(diuretics*
!advice to ta#efluids that
replaces
needed
electrolytes
(e") ,atorade*
!accurately
measuring
inta#e and
output is vital
for the client
%ith fluid
volume
overload
!to add more
electrolyte tothe body
1he goal %as met