Ncp.2
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IX. NCP June 27, 2014 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE: " hindi ko alam kung makakapagtrabaho na ako kaagad pagkagaling ko eh" as verbalized by the patient OBJECTIVES: -Vital signs, BP130/90 Temp.36.2c CR- 64 RR-20 -restlessness -difficulty in sleeping -fatigue Anxiety related to threat to/ or change in health status Within 8 hours of nursing interventions the patient will appear relaxed and the level of anxiety will reduced to a manageable level -Monitor vital signs(e.g., rapid or irregular pulse, rapid breathing) -Use presence, touch, verbalization or demeanour to remind client and to encourage expressions or clarification of needs, concerns, unknowns ’and questions - Accept client’s defences, do not confront, and argue and debate -Allow and reinforce clients personal reaction towards the threatens to wellbeing -Explain everything necessary regarding the disease -To identify physical responses associated with both medical and emotional conditions -Being supportive and approachable encourages communication -If defenses are not threatened, the client may feel safe enough to look at the behavior -Talking or otherwise expressing feeling reduces anxiety -To educate the patient regarding the disease to reduce anxiety After 8 hours of nursing interventions the patient appeared relaxed and the level of anxiety will reduced to a manageable level
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Transcript of Ncp.2
IX. NCP
June 27, 2014
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
" hindi ko alam kung makakapagtrabaho
na ako kaagad pagkagaling ko eh"
as verbalized by the patient
OBJECTIVES: -Vital signs,
BP130/90 Temp.36.2c CR- 64
RR-20 -restlessness -difficulty in
sleeping -fatigue
Anxiety related to
threat to/ or change in health status
Within 8 hours of
nursing interventions the patient will appear
relaxed and the level of anxiety will
reduced to a manageable level
-Monitor vital signs(e.g.,
rapid or irregular pulse, rapid breathing)
-Use presence, touch,
verbalization or demeanour to remind client and to encourage
expressions or clarification of needs,
concerns, unknowns ’and questions
- Accept client’s defences, do not confront, and argue and
debate
-Allow and reinforce clients personal reaction towards the threatens to
wellbeing
-Explain everything necessary regarding the disease
-To identify physical
responses associated with both medical and emotional conditions
-Being supportive and
approachable encourages communication
-If defenses are not threatened, the client may feel safe enough
to look at the behavior
-Talking or otherwise expressing feeling reduces anxiety
-To educate the patient regarding the disease to reduce anxiety
After 8 hours of
nursing interventions the patient
appeared relaxed and the
level of anxiety will reduced to a manageable
level
June 23,2014
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
“ m e d y o m a s a k i t y u n g
t i a y a n k o " as verbalized by the
patient OBJECTIVES:
-Vital signs, BP130/90
Temp.36.2c CR- 64 RR-20
-pain scale: 6/ 10 - -difficulty in
sleeping
Acute pain related to irritation of the mucosa and muscle
spasms.
Within 8 hours of
nursing interventions the Client expresses
pain diminished or disappeared.
Encourage clients to avoid foods / drinks that irritate the gastric
mucosa: caffeine and alcohol.
Encourage clients to use the meals and snacks at
regular intervals
-Instruct patient to stop smoking
Give drug therapy
according to the program
Instruct to avoid drugs are sold freely, especially those
containing salicylates.
-to stimulate the secretion of hydrochloric acid.
-Schedule regular eating helps retain
food particles in the stomach that helps
neutralize the acidity of gastric secretions.
-Smoking can stimulate ulcer
recurrence. Medicines containing
salicylates may irritate the gastric mucosa.
After 8 hours of
nursing interventions the Client
expressed pain diminished or
disappeared.
June 22, 2014
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
" ano bang mga dapat kong gawin para maiwasan na
yung pag sakit ng tiyan ko?" as
verbalized by the patient
OBJECTIVES: -sighing
-restlessness
Knowledge Deficit: the prevention and treatment of
symptoms related to the condition of
inadequate information.
Within 8 hours of nursing
interventions Clients gain
knowledge about prevention and management.
Assess the level of
knowledge and readiness to learn from
clients.
Teach the required
information: Use words that correspond with the level of knowledge of
the client. Choose a time when most convenient
and interested clients. Limit counselling sessions to 30 minutes
or less.
Assure the client that the disease can be overcome.
- Desire to learn
depends on the physical condition of
the client, the level of anxiety and mental readiness
-Individualization
counseling improve learning.
-Gives confidence can have a positive influence on behavior
change.
Within 8 hours of nursing interventions
Clients gained knowledge
about prevention and management
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
" hindi ko alam kung makakapagtrabaho
na ako kaagad pagkagaling ko eh"
as verbalized by the patient
OBJECTIVES: -Vital signs,
BP130/90 Temp.36.2c CR- 64
RR-20 -restlessness
-difficulty in sleeping -fatigue
Anxiety related to
threat to/ or change in health status
Within 8 hours of
nursing interventions the patient will appear
relaxed and the level of anxiety will
reduced to a manageable level
-Monitor vital signs(e.g.,
rapid or irregular pulse, rapid breathing)
-Use presence, touch,
verbalization or demeanour to remind client and to encourage
expressions or clarification of needs,
concerns, unknowns ’and questions
- Accept client’s defences, do not
confront, and argue and debate
-Allow and reinforce clients personal reaction
towards the threatens to wellbeing
-Explain everything necessary regarding the
disease
-To identify physical
responses associated with both medical and emotional conditions
-Being supportive and
approachable encourages communication
-If defenses are not threatened, the client
may feel safe enough to look at the behavior
-Talking or otherwise expressing feeling
reduces anxiety
-To educate the patient regarding the disease
to reduce anxiety
After 8 hours of
nursing interventions the patient
appeared relaxed and the
level of anxiety will reduced to a manageable
level
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
" mas madalas na ko kumain ngayon kaysa dati kasi pag
sumasakit na yung tiyan ko, ikakain ko
lang para mawala." as verbalized by the patient
OBJECTIVES:
- Wt: 61 kg (may 29,) Wt: 63 kg (june 27)
Imbalanced Nutrition more than body requirements related
to changes in diet
Within 8 hours of
nursing interventions the patient will
Identifies eating habits that
contribute to weight gain.
Determine current eating patterns by
having keep a Diary of what, when, and where she eats.
Determine current eating patterns by
having keep a Diary of what, when, and where she eats.
Within 8 hours
of nursing interventions the patient will
Identifies eating habits that
Contribute to weight gain.
