Assessment S: “nanghihina Ako, Hindi Ko Magawa Yung Mga Gusto

ASSESSMENT S: “Nanghihina ako, hindi ko magawa yung mga gusto kong gawin” as verbalized by the patient. O: Weak and pale in appearance. - V/S: T:38.7°C , P:72 , RR: 24 , BP: 90/60 mmHg. Presence of Body Odor Not well groomed

NURSING DIAGNOSIS Risk for SelfCare Deficit, bathing/hygiene, related to weakness as manifested by the verbalization and weak and pale appearance of the patient

PLANNING The patient will be able to take a rest and perform some bed exercise after 8 hours of continued nursing intervention.

NURSING INTERVENTION - Monitor and record vital signs

RATIONALE To identify any other deviations from normal. To assess degree of risk of self-care deficit

EVALUATON

Goal Met. The patient was able to have rest and - Determine perform some bed patient strength exercise during the and weaknesses 8-hour shift with continued nursing - Provide Adequate rest provides intervention adequate rest enough energy to the periods as well as patient comfort & safety measures Promotes blood - Turn the patient circulation from side to side - Encourage the patient to do some bed exercise

Promotes blood circulation and ease for patient when in recovery

- Provide health teachings to the patient

To provide clarification and Reinforcement