Copy Of Ncp

B. NCP with Evaluation CUES

NURSING DIAGNOSIS

ANALYSIS

NURSING OBJECTIVE

NURSING INTERVENTION

S: “mga march 30 noong magsimulang di niya maigalaw ang kanyang kanang bahagi ng kanayang katawan niya” as verbalized by the mother. “ lagi siyang irritable mula noong naoperahan siya sa ulo” as verbalized by the mother. “ako nga lang ang kinakausap niya ng matino. Minsan ayaw din niya akong kausapin” added by the mother O:  Conscious and coherent.  Not in distress

P> Impaired physical mobility

Surgical procedure to remove tumour ↓ Re occurrence of tumour on left area of the frontal lobe ↓

04-11-07 6am With in the 2 day stay patient will perform physical activity e.g. PROM, patient is free of complication of immobility AEB intact skin, absence of thrombophlebitis and normal vowel movement

Independent: Encourage and facilitate early ambulation and other ADL when possible e.g. taking daily bath

E>r/t neuromuscular impairment, affectation of the CNS S> AEB “mga march 30 noong magsimulang di niya maigalaw ang kanyang kanang bahagi ng kanayang katawan niya” as verbalized by the mother. Neuromuscular weakness on both lower extremities and r arm.

CNS affectation ↓ Motor paralysis of the lower extremities and r arm ↓ Weakness on affected extremities. ↓ Impaired physical mobility.

RATIONALE

Proper circulation and promotion of proper hygiene

Allow patient to perform task @ his own rate.

Increases pt self esteem.

Keep side rails of bed & strap of chair put on.

Promotes safe environment.

Monitor I & O, nutritional status.

Pressure sores develop more quickly in pt. w/ a nutritional deficit To optimize circulation to all tissues & relieves pressure. To promote venous return, prevents stiffness and maintains muscle strength. Prevent build up of secretion, development of hypostatic pneumonia. To optimize hydration & prevent hardening of stool

Turn pt q 2hrs Perform PROM exercises to all extremities. Encourage coughing and DBE. Encourage liquid intake unless contraindicated.

EVALUATION Date: 04-12-07 Time: 2:00pm Level of Attainment: -goal met  AEB: pt performs PROM exercises.  Normal vowel movement.  No pressure sores any complication of immobility.

 Weak in appearance  Muscle wasting on the r arm and lower extremities noted.  Irritable.  Impaired speech, only speaks 1 word at a time.\  V/S as follows: BT 36.8C PR: 100bpm RR: 18cpm c HL @ R forearm intact (-) DOB Hgb 146 Hct 44% WBC 11.2 Neutrophils 0.92 Lymphocytes 0.08 Platelet count: 295

Collaborative: Consult rehabilitation personnel or therapist as appropriate.

P>Self care deficit E>r/t neuromuscular impairement @ r arm and lower extremities. S>inability to feed self independently Inability to dress self independently Inability to bathe & groom independently.

Neuromuscular impairment secondary to PNET ↓

Inability to move lower extremities & r arm. ↓

Inability to perform task of daily living such as bathing. ↓

Self care deficit

With in the course of stay patient will perform safely self care activities with assistance of others.

Independent: Set short range goals with pt. Use consistent routines Provide pt appropriate utensils Provide assistance as needed during: >dressing/grooming. >bathing >ambulation Collaborative: Provide assistive devices for ambulation assessed by occupational therapist.

To facilitate learning and ↓ frustration

This helps pt to organize and carry out care activities. These increases opportunities for success. Reduces energy expenditure and frustration at the same time promoting safety.

Makes task easier for patient.

Level of Attainment: -goal met  AEB: pt able to do self care activities with the assistance of the mother and the student nurse

P>impaired social interaction E>r/t irritability, complication of the tumor. S>“ lagi siyang irritable mula noong naoperahan siya sa ulo” as verbalized by the mother. “ako nga lang ang kinakausap niya ng matino. Minsan ayaw din niya akong kausapin” added by the mother. Irritability. Cannot or does not speak.

Tumor on the left frontal area of the brain ↓

Surgical intervention to remove mass ↓

Re-occurrence of the tumor ↓

Destruction of neural tissues ↓

Affectation of speech And irritability ↓

Impaired social interaction.

After the shift patient will show social interaction skills and appropriate respond to the interaction being established.

Independent: Assess for the history of the child.

Provides a baseline and serves as guide in exhibiting the interaction.

Talk smoothly, with positive regard an active listening to the patient.

Establishes rapport and gains the trust of the patient.

Encourage the patient to talk even single words at a time.

Helps the patient verbalized his needs.

Coordinate with parent to provide positive reward for the compliance with the interaction.

Positive rewards gain the compliance of the patient to interactions.

Level of Attainment: -goal partially met  AEB: pt is able to utter words clearly but sometimes he is still irritable.  He is able to express what he needs by making a cry.  Rarely speaks.  Patient is able to interact with other people.