Post on 14-Apr-2018
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Nursing Prioritization
Date Identified Subjective Cues Problem/Nursing Diagnosis Justification
January 24, 2013 Minsan wala akong ganang kumain. Nutrition less than body requirement
as manifested by below the averageBMI.
This is the 1st to be prioritized because
according to Maslow, because food is one
of the basic needs of man, so the patientshould satisfy this first.
January 29, 2013 Ayaw ko ng umuwi sa barrio namin
dahil nalaman nilang nagkasakit ako
sa isip at pinagtsitsismisan ako.
Social Isolation related to traumatic
incidents causing emotional pain.
This is the 2r
to be prioritized becauseaccording to Maslow, the hierarchy
explains that before you attain thehigher level, you must surpass the
lowest level which is the physiologicneeds.
January 24, 2013 Pano ba sabihin yun? AhmBasta
ang hirap ipaliwanag kasi.
Impaired Verbal Communication as
manifested by flight of ideas.
This is the 3r to be prioritized because
according to Maslow, esteem need should besatisfy, because if the client cannot express his
feelings he cannot socialize with other people.
January 24 & 25, 2013 Jan. 24: Patay na yung tatay ko.Hindi man lang ako pinayagan na
makalabas para makapunta sa libingniya.
Jan. 25:Gusto kong umuwi paramakita yung tatay ko. Nakaratay kasi
siya dahil may sakit siya.
Disturbed thought process related tomental disorder (undifferentiated
schizophrenia).
This is the 4t
to be prioritized becauseyou need to surpass all the four levels
before attaining the highest levelwhich is self-actualization.
January 24, 2013 Nangangati ako dahil sa sugat sugat
ko.
Risk for impaired skin integrityrelated to broken skin.
This is the 5t
to be prioritized becauseaccording to the rule risk problem should
prioritized least, because actual problemshould be solve first.
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Nursing Care Plan
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective cues:
Minsan wala akong
ganang kumain, asverbalized by the client.
Objective cues:
Weight: 110 lbs. BMI:18.3
(underweight)
Nutrition less than body
requirement as evidenced
by 18.3 BMI.
Long term:
After 1 day of nursing
intervention the client
will be able to:a. Demonstrate
behaviors, lifestylechanges to regain
and/or maintainappropriate weight.
Short term:
After 30 minutes ofnursing intervention the
client will be able to:a) verbalize specific
foods that the clientcan eat to help him
for fast recoveryand foods that he
will avoid.
Independent:
Provide informationregarding specific
nutritional needs. Emphasize
importance of well
balance, nutritiousintake of foods.
Provide informationregarding individual
nutritional needs andways to meet these
needs withinfinancial constraints.
Weigh at regularintervals anddocument result.
Helps to determinenutritional needs.
To impart knowledgeand to maintain theadequacy of intake of
nutrients needed.
To monitor clientsweight.
Goal met
After 1 day of nursing
intervention the client
has increase appetite.
Goal met
After 30 minutes ofnursing intervention the
client can verbalize foodthat the patient can take
and avoid to help him forfast recovery.
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Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Cues:Ayaw ko ng umuwi sa
barrio namin dahilnalaman nilang
nagkasakit ako sa isip at
pinagtsitsismisan ako,as verbalized by theclient.
Objective Cues:
Poor eye contact Not that cooperative
Social Isolation related to
traumatic incidents
causing emotional pain.
Long term:
After 2 days of nursing
intervention the clientwill be able to:
a. express increasesense of self worth.
Short term:
After 30 minutes of
nursing intervention theclient will be able to:
a. verbalizewillingness to be
involve with others.
b. participate inactivities.
Provide attention in asincere, interested
manner.
Support anysuccesses orresponsibilitiesfulfilled, projects,
interactions with staffmembers and other
clients, and so forth.
Avoid trying toconvince the clientverbally of his or her
own worth.
Teach the clientsocial skills. Describeand demonstrate
specific skills, suchas eye contact,attentive listening,
and so forth. Discussthe type of topics that
are appropriate forcasual social
conversation, such asthe weather, local
events, and so forth.
Flattery can beinterpreted as
belittling by theclient.
Sincere and genuinepraise that the clienthas earned canimprove self-esteem.
The client willrespond to genuinerecognition of a
concrete behaviorrather than to
unfounded praise or
flattery.
The client may havelittle or noknowledge of social
interaction skills.Modeling provides a
concrete example ofthe desired skills
Goal met
After 2 days of nursing
intervention the clientexpresses increase sense
of self worth.
Goal met
After 30 minutes of
nursing intervention theclient verbalize
willingness to beinvolved with others and
participate in activities.
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Help the clientimprove his or her
grooming.
Good physicalgrooming can
enhance confidencein social situations.
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Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Cues:Pano ba sabihin yun?
AhmBasta ang hirapipaliwanag kasi, as
verbalized by the client.
Objective Cues:
Speaks/verbalizeswith difficulty;stuttering; slurring.
Difficultyexpressing thoughts
verbally.
Inappropriateverbalization
[incessant, looseassociation of ideas;flight of ideas].
Impaired Verbal
Communication as
manifested by flight of
ideas.
Long term:
After 1 day of nursing
intervention the clientwill be able to:
a. Verbalize orindicate anunderstanding of thecommunication
difficulty and plansfor ways of
handling.b. Establish method of
communication inwhich needs can be
expressed.
Short term:After 30 minutes of
nursing intervention theclient will be able to:
a. Participate well intherapeutic
communication.
Listen attentivelywhen the patient
attempts tocommunicate.
Clarify your
understanding of thepatientscommunication.
Maintain eye contactwith the patient when
speaking. Standclose, within the
patients line ofvision.
Give the patientample time to
respond.
Avoid finishingsentences for the
patient. Be calm and
accepting duringcommunicationattempts. Do not say
Decreasesfrustration and
demonstrates caring.
Eye contact lets thepatient know that
they have yourattention when trying
to communicate.Patients with
artificial airways mayneed to lip words and
standing in front of
the patient will allowthe nurse a betterview to understand
the patient.
t may be difficult forpatients to respondunder pressure, they
may need extra timeto convey thoughts.
This may lead tofrustration anddecrease the patients
trust in you.
Goal met
After 1 day of nursing
intervention the clientVerbalize or indicate an
understanding of the
communication difficultyand plans for ways ofhandling and establish
method ofcommunication in which
needs can be expressed.
Goal met
After 30 minutes of
nursing intervention theclient participate well in
therapeutic
communication.
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you understand if youdont.
Orient the patient tosurroundings. State
procedural and taskintentions when
providing care.
Not knowing who isproviding care orwhere they are can be
a stressor to the
patient. Patient mayprefer that the nursegive them some
indication of whatthey will be
experiencing,especially if it will
cause discomfort.