Ncpdx

8/11/2019 Ncpdx

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S> “Mag-iisang buwan

nako dito tapos di pa rin

ako makagalaw masyado

kase nga hirap ako.” as

verbalized by the client

O>

Alert, conscious,

coherent

Afebrile

Oriented to time,

place and

person.

Poor skin turgor

capillary refill

after 3 seconds Muscle strength

of 3/5 on upper

and 2/5 on lower

extremities

Auscultated 5-6

borborygmic

sound in each

quadrant for 1

minute.

Tympany heard

@ each quadrant w/ grade 2

pressure ulcer at

sacral area

w/Oxygen via

nasal cannula @

1 lpm

w/ heplock @ R

metacarpal

w/ suprapubic

Activity intolerance

secondary to

underlying process as

evidenced by verbal

report of weakness

Short Term Goal:

After 8 hours of nursing

intervention, patient

will be able to identify

negative factorsaffecting activity

tolerance and able to

eliminate or reduce

their effects when

possible.

Long Term Goal:

After 2-3 days of

nursing intervention,

client will demonstrate

a decrease inphysiological signs of

intolerance.

INDEPENDENT:

>Monitored for

abnormal vital signs.

>Assessed the muscle

strength and ADL.>Note client reports of

weakness, fatigue, pain,

difficulty accomplishing

task.

>Plan care to carefully

balance rest periods

with activities.

>Provide positive

atmosphere, while

acknowledging

difficulty of thesituation for the client.

>Encouraged

verbalization of

feelings.

>Provided comfort

measures such as

therapeutic touch and

quiet & clean

environment.

DEPENDENT:

>Check CBG and other

laboratory values.

>Administer

medications as

prescribed by the

doctor.

COLLABORATION:

>Collaborate with

dietician and other

health care team.

>Establish a baseline

data and check

patient’s condition.

>Check the functionalrange.

>Symptoms may be

result or may

contribute to

intolerance of activity.

>To reduce fatigue

>To help in minimizing

frustration andrechanneling energy

>To enhance ability to

participate in activities.

>To help patient to

relieve anxiety,

irritation and

uncomfortability to the

situation.

>Provide comfort and

safety.

>Check for abnormality

in the values.

>To relieve any possible

pain of discomfort.

>Modify the food and

other health services

appropriate to the pt.

Short Term Goal:



was able to identified

negative factorsaffecting activity

tolerance and able to

eliminate or reduce

their effects when

possible.

Long Term Goal:

After 3 days of nursing


was able to

demonstrated adecreased in

physiological signs of

intolerance.

8/11/2019 Ncpdx


catheter to urine

bag

w/ edema on

upper & lower

extremities

BP: 130/70

T: 36.4

H: 107

R: 19

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S> “Masakit na ang sugat

ko sa likod at tila ba hindi

ko maintindihan kung

kalian gagaling.” asverbalized by the client

O>

Alert, conscious,

coherent

Afebrile

Oriented to time,

place and

person.

Poor skin turgor

capillary refill

after 3 seconds Muscle strength

of 3/5 on upper

and 2/5 on lower

extremities

Auscultated 5-6

borborygmic

sound in each

quadrant for 1

minute.

Impaired skin integrity

r/t physical

immobilization as

evidenced by grade 2pressure ulcer

Short Term Goal:


intervention, patientwill be able to

demonstrate

understanding of plan

to heal skin and

prevent re-injury

Long Term Goal:

After 2-3 days of


client will display

timely healing ofpressure sores without

complication.

INDEPENDENT:

> Assess site of skin

impairment anddetermine cause

>Monitor site of skin

impairment at least

once a day for color

changes, redness,

swelling, warmth, pain,

or other signs of

infection. Determine

whether the client is

experiencing changes in

sensation or pain. Pay

special attention to

high-risk areas such as

bony prominences,

skinfolds, the sacrum,

and heels

> Monitor the client's

> To provide the basis

for additional testingand evaluation to start

the assessment process

>To inspect systematic

& identify impending

problems early

>To avoid harsh

cleansing agents, hot

Short Term Goal:


intervention, patientwas able to

demonstrated

understanding of plan

to heal skin and

prevent re-injury

Long Term Goal:

After 2-3 days of


client was able to

displayed timelyhealing of pressure

sores without

complication.

8/11/2019 Ncpdx


Tympany heard

@ each quadrant

w/ grade 2

pressure ulcer at

sacral area

w/Oxygen vianasal cannula @

1 lpm

w/ heplock @ R

metacarpal

w/ suprapubic

catheter to urine

bag

w/ edema on

upper & lower

extremities

BP: 130/70

T: 36.4

H: 107

R: 19

skin care practices,

noting type of soap or

other cleansing agents

used, temperature of

water, and frequency of

skin cleansing.

> Monitor the client's

continence status, and

minimize exposure of

skin impairment and

other areas of moisture

from incontinence,

perspiration, or wound

drainage.

> Do not position theclient on site of skin

impairment. If

consistent with overall

client management

goals, turn and position

the client at least every

2 hours. Transfer the

client with care to

protect against the

adverse effects of

external mechanical

forces such as pressure,

friction, and shear.

water, extreme friction

or force, or cleansing

too frequently

> Moisture from

incontinence

contributes to pressure

ulcer development by

macerating the skin

>To prevent furtherpressure ulcer on the

site of impairment

Ncpdx

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