Ncp
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CUES Subjective: The patient verbalizes: “Dali ako kapuyon kag daw kabudlay gid maghulag”
Objective: • Poor hygiene, body odor upon assessmen t • Muscle weakness • Decreased ability/incr eased need for assistance in performing self-care • PR= 108 bpm
NURSING RATIONALE DIAGNOSIS • Self Care • Dyspnea deficit related may be to fatigue severe and secondary to often increased work interferes of breathing with the and insufficient patient’s ventilation and activities. oxygenation The work of breathing is energy depleting. Often the Definition: patient A state in which cannot an individual is participate unable to in mild perform self-care exercise because of and unable insufficient to perform physiologic or self-care psychologic because of energy to endure dyspnea or complete which required or causes desired activity. fatigue. As the work of breathing increases over time, the Reference: accessory muscles are • Nurses Pocket recruited in Guide an effort to • by Donges, breath. Marilynn • 4th Edition • Page 56 Reference:
GOAL After 72 hours of nursing interventions the client will be able to: • Perform selfcare activities within level of own ability. • Demonstrate technique/lif estyle changes to meet own needs. • Participate in physical therapy and rehabilitatio n.
NURSING INTERVENTION •
Independent: • Determine current capabilities (0-4 scale) and barriers to participation in care. •
Involve patient in formulation of plan of care at level of ability.
•
Encourage self-care. Work with present abilities; do not pressure patient beyond capabilities. Provide adequate time for patient to complete tasks. Have expectation of improvement and assist as needed.
•
Encourage/assist with routine mouth/teeth care daily.
•
RATIONALE •
•
•
•
• Encourage patient to begin to bathe self, walk and drink fluids. Discuss energy conservation measures.
EVALUATION
After 72 hours of nursing interventions, Goal partially met: • Client was able to perform selfEnhances sense care of control and independentl aids in y except on cooperation and bathing which development of still needs independence. assistance. • Client was Doing for able to use oneself controlled enhances feeling breathing of self-worth. while Failure can bending, produce bathing and discouragement walking. and depression. • Client was unable to perform postural Reduces risk of drainage gum correctly. disease/tooth • Client was loss; promotes proper fitting of able to dentures. perform activities of daily living to As conditions alternate with resolves, patient rest periods will be able to to reduce do more but fatigue and needs to be dyspnea. encouraged to • Client fully avoid increasing dependence. participated in physical Identifies need for/level of interventions required.
Objective: • Poor hygiene, body odor upon assessmen t • Muscle weakness • Decreased ability/incr eased need for assistance in performing self-care • PR= 108 bpm
NURSING RATIONALE DIAGNOSIS • Self Care • Dyspnea deficit related may be to fatigue severe and secondary to often increased work interferes of breathing with the and insufficient patient’s ventilation and activities. oxygenation The work of breathing is energy depleting. Often the Definition: patient A state in which cannot an individual is participate unable to in mild perform self-care exercise because of and unable insufficient to perform physiologic or self-care psychologic because of energy to endure dyspnea or complete which required or causes desired activity. fatigue. As the work of breathing increases over time, the Reference: accessory muscles are • Nurses Pocket recruited in Guide an effort to • by Donges, breath. Marilynn • 4th Edition • Page 56 Reference:
GOAL After 72 hours of nursing interventions the client will be able to: • Perform selfcare activities within level of own ability. • Demonstrate technique/lif estyle changes to meet own needs. • Participate in physical therapy and rehabilitatio n.
NURSING INTERVENTION •
Independent: • Determine current capabilities (0-4 scale) and barriers to participation in care. •
Involve patient in formulation of plan of care at level of ability.
•
Encourage self-care. Work with present abilities; do not pressure patient beyond capabilities. Provide adequate time for patient to complete tasks. Have expectation of improvement and assist as needed.
•
Encourage/assist with routine mouth/teeth care daily.
•
RATIONALE •
•
•
•
• Encourage patient to begin to bathe self, walk and drink fluids. Discuss energy conservation measures.
EVALUATION
After 72 hours of nursing interventions, Goal partially met: • Client was able to perform selfEnhances sense care of control and independentl aids in y except on cooperation and bathing which development of still needs independence. assistance. • Client was Doing for able to use oneself controlled enhances feeling breathing of self-worth. while Failure can bending, produce bathing and discouragement walking. and depression. • Client was unable to perform postural Reduces risk of drainage gum correctly. disease/tooth • Client was loss; promotes proper fitting of able to dentures. perform activities of daily living to As conditions alternate with resolves, patient rest periods will be able to to reduce do more but fatigue and needs to be dyspnea. encouraged to • Client fully avoid increasing dependence. participated in physical Identifies need for/level of interventions required.
