Ncp Potts Disease
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Overview
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Cues
Nursing Diagnosis
SUBJECTIVE: Self-bathing/ “ Ang hirap ng hygiene deficit ganito, nakahiga related to musculona lang lagi, kahit skeletal impairment paligo inaasa sa as evidenced by iba,” as verbalized inability to wash by the patient body or body parts, obtain or get to OBJECTIVE: water source, get in > patient has been and out of bedridden ever bathroom. since she was hospitalized because of spinal cord injury
Planning
Implementation Independent:
Rationale
GOAL: 1) Determine existing After 1 day of conditions nursing affecting ability of intervention, the individual to care patient will for own needs, i.e. perform self-care spinal cord injury. activities within 2) Determine level of own individual ability strengths of client 3) Note whether EXPECTED deficient is OUTCOME: temporary or The patient will: permanent, should 1) Identify decrease or individual increase in time areas of 4) Promote client/ SO weakness/ participation in needs problem 2) Demonstrate identification and techniques/ decision making. lifestyle 5) Develop plan of changes to care appropriate to meet selfindividual care needs situation, 3) Identify scheduling personal activities to resources conform to clients
> To identify causative/ contributing factors
Evaluation Evaluate responses to interventions, teachings and actions performed.
*The client was > To assess able to perform degree of self-care disability activities within >To assess degreelevel of own of disability ability. Goal was met
>enhances commitment to plan, optimizing outcomes > to assist in correcting/ dealing with situation
that can provide assistance
normal schedule. 6) Assist with rehab program 7) Allow sufficient time for client to accomplish tasks to fullest extent of ability 8) Assist with necessary adaptation to accomplish ADL’s. Begin with familiar, easily accomplished tasks. 9) Review/modify program periodically to accommodate changes in abilities Dependent: 10)Administer medication regimen Collaborative: 11)Consult with dietitian/nutritional support team
> To enhance capabiities > To enhance capabilities
>To encourage client and build on successes.
>Assist patient to adhere to plan of care to fullest extent >To provide continuity of care > To provide continuity of care
Nursing Diagnosis
SUBJECTIVE: Self-bathing/ “ Ang hirap ng hygiene deficit ganito, nakahiga related to musculona lang lagi, kahit skeletal impairment paligo inaasa sa as evidenced by iba,” as verbalized inability to wash by the patient body or body parts, obtain or get to OBJECTIVE: water source, get in > patient has been and out of bedridden ever bathroom. since she was hospitalized because of spinal cord injury
Planning
Implementation Independent:
Rationale
GOAL: 1) Determine existing After 1 day of conditions nursing affecting ability of intervention, the individual to care patient will for own needs, i.e. perform self-care spinal cord injury. activities within 2) Determine level of own individual ability strengths of client 3) Note whether EXPECTED deficient is OUTCOME: temporary or The patient will: permanent, should 1) Identify decrease or individual increase in time areas of 4) Promote client/ SO weakness/ participation in needs problem 2) Demonstrate identification and techniques/ decision making. lifestyle 5) Develop plan of changes to care appropriate to meet selfindividual care needs situation, 3) Identify scheduling personal activities to resources conform to clients
> To identify causative/ contributing factors
Evaluation Evaluate responses to interventions, teachings and actions performed.
*The client was > To assess able to perform degree of self-care disability activities within >To assess degreelevel of own of disability ability. Goal was met
>enhances commitment to plan, optimizing outcomes > to assist in correcting/ dealing with situation
that can provide assistance
normal schedule. 6) Assist with rehab program 7) Allow sufficient time for client to accomplish tasks to fullest extent of ability 8) Assist with necessary adaptation to accomplish ADL’s. Begin with familiar, easily accomplished tasks. 9) Review/modify program periodically to accommodate changes in abilities Dependent: 10)Administer medication regimen Collaborative: 11)Consult with dietitian/nutritional support team
> To enhance capabiities > To enhance capabilities
>To encourage client and build on successes.
>Assist patient to adhere to plan of care to fullest extent >To provide continuity of care > To provide continuity of care
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