NURSING CARE PLAN
NURSING CUES DIAGNOSIS [Link] age and developmental issues. [Link] concomitant medical problems or existing conditions that may be factors for care. [Link] individual strengths and skills of the client and note whether deficit is temporary or permanent,should, increase or decrease with time. [Link] or assist with meeting the pts needs when she is unable to meet own needs. [Link] pts /SOs participation in problem identification and desired goals and decision making. 1. This factors affect the ability of individual to participate in own(pts) care. After 8 hours of duty, goal met, the patient was able to identify areas of weakness or 2. To know considerations needs and perform selfwhen providing pts care. care activities within level of own ability. 3. To know limitations during care process. 4. Personal care assistance is part of nursing care and should not be neglected while self-care independence is promoted and integrated. 5. Enhances commitment to plan, optimizing outcomes and supporting recovery or health promotion After rendering effective nursing care, goal partially met, the patient was not able to demonstrate techniques and lifestyle changes to meet pateints self care needs. OBJECTIVE INTERVENTION RATIONALE EVALUATION
Objective cues: Impaired to put clothing on upper or lower body; remove clothing Unpleasant body odor Poor grooming Reported not taken a bath since admission Dependent on SO
Self-care deficit Short term Objective: related to impaired mobility After 8 hours of duty, the patient will be able to identify areas of weakness or needs and perform self-care activities within level of own ability
Long Term Objective: After rendering effective nursing care, the patient will be able to demonstrate techniques and lifestyle changes to meet patients self care needs.
BP- 140/90 mmHg T- 37 C
RR- 16 cpm PR- 85 bpm
7. develop plan of care appropriate to individual situation, scheduling activities to confirm the clients usual or desired schedule [Link] time for listening to the patients or SO feelings and concerns 9. practice and promote short term goal setting and achievement.
10. Provide for communication
6. To promote cooperation from the patient which is appropriate to the individual situation 7. To discover barriers to participation in regimen and to work on problem solutions 8. To recognize that today success as important as any long term goal, accepting ability to do one thing at a time and conceptualization of self care in a broader sense 9. Enhances coordination and continuity of care 10. To reduce risk of injury and promote successful community functioning. 11. Provide clarification, reinforcement; allows periodic review by client/caregivers.
Subjective cues: Kas-ap pa jud tawon ko nakaligo sukad naadmit ko, as verbalized by the patient
among those who are involved in caring for or assisting the client [Link] safety concerns .modify activities or environment.
[Link] instructions from
other members of the healthcare team and provide written copy.