Tetanus 3

Date July 23, 2009

Problems encountered (actual and resolved) Actual problems that are identified are and have been resolved last Aug.1, 2009: First is ineffective airway clearance. As evidence by relatives verbalization “ Inuubo pa rin siya.” And based on the assessment done (+) productive cough, (+)Wide eyed and (+)Restlessness Because of the necessary nursing interventions that have been done the pt maintained a patent airway. Second is disturbed sleep pattern. As evidence by verbalization of the husband of the pt “onti lang ang tulog niya mga 2 hours at paputolputol” And based on the assessment done that there are (+) sunken eyeballs and weakness. It should be the second priority because the client is experiencing a insufficient time or period of sleep. The necessary nursing interventions should be done for the client to be able to maintain a comfortable environment. After doing so, the client verbalized improvement in sleep pattern and can sleep now from 4-8 hours. Third is is impaired physical mobility. It should be identify for the client to have sufficient energy to endure or complete required or desired daily activities. The problem was evidence by verbalization of the pt husbands “di nga siya pwedeng tumayo sabi ni Dok” and positive immobility, weakness, Doctors order of CBR. And (+) Tracheostomy based on the assessment done. Because of the necessary nursing interventions that have been formulated the client was able to do simple task. And Forth impaired skin integrity. As positively evidence by skin disruption of skin surface and as verbalized by the husband of the pt “Di pa magaling ung suagat niya gawa ng pag papaopera niya sa lalamunan” and(+) Floppy skin,76 yrs old and (+) Tracheostomy. Necessary nursing interventions should be done; and after doing so the client’s wound becomes dry and clean.

Aug 1, 2009

There is a potential problem that had been identified during our contact with the client and this is risk for infection due to the disruption of the skin which is the primary defense. Necessary nursing interventions should be done to prevent infection and complications.