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Nc process geria Nc process geria Document Transcript

  • FAR EASTERN UNIVERSITY INSTITUTE OF NURSING Requirement on Nursing Elective-Geriatrics NURSING CARE PROCESSSUBMITTED BY: RONDA, JENNAN A.SUBMITTED TO: PROF. PADILLA, RN, MAN
  • TABLE OF CONTENTS I. CLINICAL SUMMARY a. Biographic data b. History of present illness c. Past medical history d. Familial history e. Physical assessment f. Patterns of functioning g. Daily activity patternsII. Nursing care plan a. Problem identification b. Problem prioritization c. Nursing care plan d. Discharge planning
  • I. CLINICAL SUMMARY a. Biographic dataName: A.M.R.Address: 1015 Bangon-Sarimanok st., Marawai City, Lanao Del NorteAge: 65 years oldGender: MaleReligious: MuslimOccupation: Businessman, Ministry EmployeeMarital Status: MarriedChief Complaint: Difficulty of Breathing b. History of present illnessPatient A.M.R. experiences generalized body weakness and severe dizziness.He was askedabout his daily activities and said that he mostly works at the office for the whole day. Hejust finishes some paper works, have meetings and at times goes on a Business trips. Andhe drives his car to work. Moreover, the patient added, “Hind naman ako palainom ng tubigkadalasan tea ang iniinom ko” The patient also stated that, “Nagpipigil din akong ihi minsandahil kadalasan nasa meeting ako.” The patient likeseating grilled food especially grilledchicken. But he still makes sure he eats a lot of vegetables and fruits as well. c. Past medical historyAs the patient stated, he never had any kind of childhood diseases except chicken pox andmeasles. The patient has never been immunized because his family could not afford it.Thepatient has no known allergy and has neither accidents nor injuries. The patient had recent
  • travel last January 2013 in Malaysia for his business trip. The patient has no any other vicesand never drinks alcoholic beverages. He tried smoking when he was younger but nowclaims that he has stopped. d. Familial historyBased on the interview, the mother of the patient had Hypertension and his father as well.But both parents died during the war.He has 10 siblings but one of them died at a youngage and another died at old age, so only 9 of themare in the family. And he said that 6 ofthem have hypertension. e. Physical assessmentReview of System:General: (-) weight loss; (-) fatigue; (-) loss of appetite; (+) dizziness.Interpretation:The patient is conscious, coherent, oriented to time, place and person. Well groomed, lookshis age, with the ff VS: BP120/80 mmHg, CR 80 bpm, RR – 20 cpmAnalysis:Relaxed, erect posture; coordinated movement, increased blood pressure due to fluidoverload and production of vasoactive hormonesSkin: (-) Itchiness; (+) dryness; (-) sweaty; (-) paleness; (-) hair colorInterpretation:
  • The patient has a light brown complexion; skin has a normal degree of elasticity, mobilityand thickness. With no superficial blood vessels, no lesions, hair are thin in distribution andgray in color. Nails are smooth, pink and have normal folds.Analysis:Presence of dehydration.Heent: (-) headache; (-) vertigo; (+) vision blur; (-) double vision; (-) deafness; (-) tinnitus;(-) ear discharge; (-)smell change; (-) nose bleed; (-) nasal obstruction; (-) pain around thenose; (-) toothache; (-) sore throat; (-) difficulty of swallowing; (+) use of glassesInterpretation:no tumor and patients hair is black. Asymmetrical face, with abnormal facie deviation tothe right, no involuntary facial movement.Eyes: eyebrows are symmetrical, colorblack, the eyelashes grows outwards and upwards.Eyelids, no tremors and no edema with lagging of the eyelids. Sclera is white, , iris is black,pink conjunctiva.Ears: Auricles are symmetrical, Ear canal is patent, no discharge, mucosal wall is pink, noexudates.Nose: nasal vestibule are patent, no discharge and no edema. Nasal septum in the midline, ,no perforation and mucosal wall is pink, no discharge.Mouth: lips are asymmetrical, moist, pink, no lesions, the soft and hard palate are pink incolor and no lesions noted.Neck: (-) pain; (+) limitation of movement; (-) mass; neck vein engorgement.Interpretation:
  • Neck: the neck is supple, symmetrical, no mass and no lesion. The trachea is in the midlineand not deviated. Lymphnodes are not enlarged, thyroid glands is not enlarged. There is noneck vein engorgement.Analysis:The normal limitation to movement at each joint helps decrease the likely hood andpotential of inadvertently damaging a joint even further or surrounding tissues, and thisincreases the safety of the massage for the client.Respiratory: (+) dyspnea; (-) chest pain; (-) cough; (-) sputum; (-) hemoptysis; (+) crackles;(+) wheezes.Analysis:Nose straight, without flaring or discharge; nares patent, mucosa pink and moist; septummidline, without masses or perforation.Crackles on the lower left lung field; wheezingsound over the trachea.Reference: Medical-Surgcal Nursing, Clinical Management for Positive Outcomes, 8thEdition, Volume 2, page 1531Gastrointestinal: (-) abdominal pain; (-) nausea; (-) vomiting; (-) dysphagia; (-) diarrhea; (-)constipation; (-) hematemesis; (-) melena; (-) hematochezia’ (-) regurgitation; (N) bowelmovementInterpretation:
  • Abdomen: soft, globular, non-tender, no palpable masses, no costovertebral angletenderness, normoactive bowel sounds.Analysis:Bowel sound present in all four quadrants. Liver and spleen palpable. Abdomen soft,nontender, no massesor rebound tenderness; muscle tone firm, relaxed.Reference: Medical-Surgcal Nursing, Clinical Management for Positive Outcomes, 8thEdition, Volume 1, page568Gastrourinary: (+) dysuria; (N) frequency of urine; (-) urgency; (-) hesitance; (-) polyuria; (-) hematuria; (-) incontinence; (-) genital pruritus; (-) urethral dischargeInterpretation:Difficulty voiding, changes in urine flow.Extremities: (+) edema; (-) swelling of joints; (-) stiffness and numbnessInterpretation:Adjust fluid intake to avoid volume overload and dehydration. f. Patterns of FunctioningA. PSYCHOLOGICAL HEALTH1. COPING PATTERNS When he and his family encounters problem, he easily handles them since theyeffectively express their emotions through communication with each other. He doesn’t
  • dwell with the problems if ever it arises. He is very tranquil and composed in handlingthings but sometimes, there are times that he gets angry easily and lose control of histemper. But then apologizes for hos irrational behavior because he knows getting angryscares his family.INTERPRETATION: The client has effective coping skills since he was able to solve problems with hisfamily through the help of communication. He knew how to properly address and manageand handle the problems although there are some instances that when he is out of control.ANALYSIS: Coping strategies vary among individuals and are often related to the individual’sperception of the stressful event. (Fundamentals of Nursing, Kozier, 7th edition pg. 1020) A coping strategy is a natural or learned way of responding to a changingenvironment or specific problem or situation. (Fundamentals of Nursing, Kozier, 8th editionpg. 1068)2. INTERACTION PATTERNSHe has good relationship with his family, friends and neighbors. He spends time with themand talks to them when his free. He is well-rounded and well-loved by his loved ones.Through interaction, he can easily express himself and can easily adjust with differentsituations. Upon our interview, he is very expressive, honest and very detailed inanswering the questions being asked to him. He explains things very clearly, maintains aneye contact while speaking as well as very sincere in giving out details about his life. Hisfacial expression, body language is congruent with his words, feelings and to the situations.
  • He shares some of the significant accounts of his life without hesitation and distrustinstead; he shares them with full honesty and openness. In like manner, he can easily gainthe trust of the people since he trusts them back with full sincerity. During the interview,we observed that the client is very honest and genuine in sharing some details of his life. Heshares his life stories like he was just narrating it to someone whom he is close with andwhom he trusts very well.INTERPRETATION: The client has good interaction skills to the people around her. He can easily relatewith them since he is very open, honest and sincere with his words and actions asevidenced by his being expressive in any possible ways or instances. He can easily trustother people and vice versa.ANALYSIS: Language and communication assessment tests the ability to express andcomprehend one’s environment. (Medical –Surgical Nursing, 8th edition, Volume 2, page1776) Communication is an essential part of establishing a relationship with the client andher family. It is also an important for developing effective working relationships withhealth care colleagues. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page 321) Communication can be a transmission of feelings or a more personal and socialinteraction between people. It is basic component of human relationships. (Kozier andErb’s Fundamentals of Nursing, 8th Edition, Vol.1 page 460) Communication between two participants involves all of the verbal and non-verbalbehaviour that they perceive in each other. Non-verbal communication includes tone and
  • volume of voice, eye contact, facial expression, body posture and other body language. Weexpect to find congruence between the words and non-verbal cues; the words match thefeeling and tone of the body. (Medical –Surgical Nursing, 8th edition, Volume 1, page 423)3. COGNITIVE PATTERNS The client relates to reality and is conscious of what is happening to his environmentand to the people around him. His thoughts, ideas and perceptions in life are in congruentwith the situations being related to him. During the interview, the client is conscious,coherent and oriented to time, place, person, event or situation. When asked about variousquestions, he was able to recall significant information about his life and was able toexpress them properly and appropriately.INTERPRETATION: The client is well-oriented to her environment and the people. She has good cognitionof things and her ideas, thoughts and perceptions relate to the right situations. She hasgood memory since she was able to recall and relay some of the significant experiences inher life.ANALYSIS: The mental status examination includes assessment of level of consciousness,orientation, memory, mood and affect, intellectual performance, judgment and insight, andlanguage and communication. (Medical –Surgical Nursing, 8th edition, Volume 2, page1775)4. SELF-CONCEPT PATTERNS
  • The client views himself as a disciplined, hardworking, persistent and positivethinker. He believes and trusts his capabilities and potentialities and has self-determination. When he has things to accomplish in life, he is determined and strong-minded that he can achieves them as long as he believes in himself. He also believes that ifyou think that these things will happen, it will happen. On the other hand, he is satisfiedabout himself and has uncertainties in life.INTERPRETATION: The client is satisfied with what God has given him and with who and what he is rightnow as a person. He strongly believes in the power of his own capabilities andpotentialities and what it can do once used and strengthened. He believes that it dependsupon the person how he/she will strive to achieve their goals in life. Furthermore, whatmakes him happy is his family.ANALYSIS: Self-concept is one’s mental image of oneself. A positive self-concept is essential to aperson’s mental and physical health. Individuals with a positive self-concept are better ableto develop and maintain interpersonal relationships and resist psychological and physicalillness. An individual possessing a strong self-concept should be better able to accept oradapt to changes that may occur over the lifespan. How one views oneself affectsinteraction with others. (Kozier and Erb’s Fundamentals of Nursing, 8th Edition, Vol.2 page1003) Viewing one’s self includes his or her self-worth/conception, comfort, body image,feeling state. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page 190)5. EMOTIONAL PATTERNS
  • The client admitted that he is emotional in some instances such as when he hasproblems relating to family matters. He easily gets irritated or angry. However, he caneasily manage himself by trying to control his temper and emotions. Sometimes, whenconfronted with situations that involve heavy emotions or feelings, he can’t easily expressor voice it out with his family. Upon our interview, the client cried when he tries to recalland remember those sad times he had experienced and those disheartening moments of hislife. When tried to calm him down and gave him emotional support through touch therapyand therapeutic communication, he said, “hindi ko kasi mapigilan ang sarili kong umiyakkapag naaalala ko yung mga malulungkot na pangyayari sa buhay ko.”INTERPRETATION: The client is very emotional and sensitive especially when it comes to his family. Hecan handle and manage things, however, there are instances that he hardly expressedhimself and pour out his true feelings and emotions because he kept it by himself. He easilycries when remembering sad experiences happened in hislife.ANALYSIS: Expressing of emotions includes thoughts and actions to relieve emotional distress.It does not improve the situation but makes the person feel better. (Kozier and Erb’sFundamentals of Nursing, Vol 2 page 1068)6. SEXUALITY PATTERNSThis pattern was not assessed as the patient was not comfortable at this topic.7. FAMILY COPING PATTERNS
  • As a family, they can easily cope up with their problems since they approach thatsituation appropriately by means of open communication with one another. Through goodcommunication, they can solve their problems easily. He even uttered, “kahit anong bagay oproblema natin sa buhay at pamilya, nadadaan yan sa maayos na pag-uusap. Kelangan langna makinig tayo sa sinasabi ng bawat-isa at irespeto kung ano man ang magiging desisyonnila. Kung makakabuti iyon para sa lahat, mas ok yon.” In addition, the client said that whenconfronted with problems, he knew that God is there for him and his family, guiding anddirecting them to the right path of decisions. Her faith to God is extremely and undoubtedlyunfailing. Through prayers and effective communication with each of the family members,he can solve problems effortlessly.INTERPRETATION: The client manages to use communication as an influential and powerful tool insolving their family members. However, when a problem in their family was not addressedproperly and effectively, conflicts and consequences usually occur. When these situationsusually happen, she relies to God as his protector.ANALYSIS: The effectiveness of family communication determines the family’s ability tofunction as a cooperative, growth-producing unit. Messages are constantly beingcommunicated among family members, both verbally and non-verbally. The informationtransmitted influences how members work together, fulfill their assigned roles in thefamily, incorporate family values, and develop skills to function in society. Families thatcommunicate effectively transmit messages clearly and members are free to express theirfeelings without fear of jeopardizing their standing in the family. Family members support
  • one another and have the ability to listen, empathize, and reach out to one another in timesof crisis. (Kozier and Erb’s Fundamentals of Nursing, 8th Edition, Vol.1 page 434)B. SOCIO-CULTURAL PATTERNS1. CULTURAL PATTERNS The client was raised as a person possessed with qualities such as being God-fearing, humble, compassionate, sincere, genuine, kind-hearted and forgiving. His parentstaught him good morals and right conducts that made his whole personality desirable.Likewise, he grew up with culturally-sensitive beliefs and is bounded with norms andtradition of their family. He still believes in cultural beliefs and even practices them untilnow.INTERPRETATION: The client valued the cultural beliefs that had been passed to him by his parents andby past generations. He believes in them since it was part of his life.ANALYSIS: Cultural and developmental considerations are essential elements in knowing theclient well and being able to plan individualized care that will focus on client strengths aswell as special needs. (Fundamentals of Nursing, Kozier & Erbs, 7th edition, page 413). Culture is a complex whole in which each part is related to every other part. Itdepends on an underlying social matrix, including knowledge, belief, art, law, morals andcustoms. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page 315)2. SIGNIFICANT RELATIONSHIPS
  • He has good relationship to his family. They are very bonded to each other and are able torelate to each other’s individualities and differences. They loved and valued each other asevidenced by her verbalization of how close they are. He highly values and respects hisfamily, relatives and friends. Hisfamily are the most important people in his life.INTERPRETATION: The client has good relationship with his family and to people around him. He highlyrespects and values his family since they are the most important people in his life.ANALYSIS: It is important to give attention to people we considered as significant to our lives.Valuing others strengthens the relationship or commitment we have. (Kozier and Erb’sFundamentals of Nursing, Vol.1 page 318)3. RECREATION PATTERNS The patient’s recreational activities’ aside from his work includes reading, watchingand cooking.He articulated, “mahilig ako magbasa at manoud ng news kahit noon pa. Atnatutu kong magluto para sa pamilya ko kasi minsan busy si misis”INTERPRETATION: The client’s recreational activities are his routinely works and some household choresonly. He is fond of watching television as his past time.ANALYSIS: An activity-exercise pattern refers to a person’s routine of exercise, activity, leisureand recreation. It includes activities of daily living that require energy expenditure such as
  • cooking, working and home maintenance. (Kozier and Erb’s Fundamentals of Nursing, 8thEdition, Vol.2 page 1106)4. ENVIRONMENT PATTERNS The patient’s environment is very clean since they have a maid who cleans itregularly. Hiswife loves planting and they are both nature-lover. He regularly cleans theirbackyard and wants his environment to be clean and green all the time. He also added thathe is satisfied with their living place since the environment is conducive for a good, safeand healthy living.INTERPRETATION: The client is fully aware of the importance of a clean environment to a healthy livingthat’s why he regularly has his place cleanedbecause he believes that a clean and greenenvironment promotes good health and prevents from acquiring an illness.ANALYSIS: People are becoming aware of their environment and how it affects their health andlevel of wellness. Different factors of environment affect a person’s health such asgeographic location, pollution, etc. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page301)5. ECONOMIC PATTERNSHe practices budgeting in their family. His salary as well as hiswife combined together fortheir family’s expenses and other needs. They koew how to do budgeting and often, theycan manage to allocate their resources and money effectively and sufficiently. There is also
  • enough money to be spent on other basic necessities in their family such as allocation formedical or health services when a family member needs it.INTERPRETATION: The client knows how to properly allocate and utilize the resources available.Through budgeting, he and his family were able to use the money effectively in supplyingfor their daily needs. He is very economical and efficient in handling financial matters.ANALYSIS: The economic resources needed by the family are secured by adult members. Thefamily protects the physical health of its members by providing adequate nutrition andhealth care services. (Kozier and Erb’s Fundamentals of Nursing, 8th Edition, Vol.1 page429)C. SPIRITUAL PATTERNS1. RELIGIOUS BELIEFS AND PRACTICES The client is very faithful and loving person. She is very religious and pays a lot of respect, trust and love to God. He prays regularly five times a day and on Fridays he goes to the mosque to pray.He is very hopeful and optimistic about things and when faced with problems, he knows that God will not let him down. On the contrary, when it comes to religious practices, he is still doing most of them since he grew with his parents valuing religious beliefs and practices. INTERPRETATION:
  • The client values, respects and loves God with all her heart. He prays to Him and goesto mosque. He believes that when you are facing problems in life, God will not let you solveit alone. He grew up with religious beliefs and practices, that’s why, he values them untilnow. ANALYSIS: Religion gives a person a frame of reference and a perspective with which toorganize information. It may be considered a system of beliefs, practices, and ethical valuesabout divine or superhuman power or powers worshipped as the creator and ruler of theuniverse. (Kozier and Erb’s Fundamentals of Nursing, 8th Edition, Vol.1 page 315)2. VALUES AND VALUING The client’s values are shaped by his parents. Because of his parents’ teachings about life, he grew up decisive and determined in life. That’s why, whenever he encounters problems, he tries his best to solve them eagerly and with full responsibility and determination.INTERPRETATION: The client gives importance to values and morality since his parents at a young age taught him different values of life. Among these includes his being self-determined in decision-making. ANALYSIS:
  • Values are enduring beliefs or attitudes about the worth of a person, object, or action.Values are important because they influence decisions and actions and ethical decisionmaking. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page 80) g. Daily activity patterns ADL Before During Interpretation Analysis Hospitalization HospitalizationNutrition The client When hospitalized, The client eats Nutrition is the usually eats fish, the client’s served healthy foods sum of all the vegetables, foods consist of even before he interactions vegetables (with fruits, meat and was between an sabaw), fish, and poultry. He rice. But she only hospitalized. organism and athe doesn’t eat pork eats small of what But during his food it consumes. since it is is being served to hospitalization, In other words, against his her approximately he eats little of nutrition is what a religion. ½ cup of rice only. what is served person eats and The client prefers because he gets how the body uses to eat fruits stomach ache it. The body’s most specially after taking his and he vomits basic nutrient is medications the foods that water. Because because he is easily he eats. The every cell requires irritated by the client prefers to a continuous medications. eat fruits after supply of fuel, the taking his most important The client medicines to nutritional need , verbalized:  tsaka kung prevent the after water, is for minsan wala irritation that nutrients that akong ganang he feels after provide fuel, or kumain. Medyo drinking energy. Kozier, hirap ding medicines. Fundamentals of akong lumunok Nursing, 8th at ngumuya kaya madalas edition) puro prutas na lang ang kinakain ko, tulad ng ubas at orange.”
  •  According to his daughter, he eats only 1/2cup of rice and refuses to eat more because of the discomfort that he feels.  Lack of interest in food  Prefers eating fruits rather than a mealElimination The client’s The client The client Urinary bowel defecates regularly defecates elimination is elimination is and urinates regularly, and essential to health, urinates and voiding can be regular and normally and is without postponed for only normal with no wearing diaper. He difficulty and so long before the difficulties or usually consumes 4 pain. urge normally any discomforts diapers each day. becomes too great as well as to his according to his He uses to control. urination daughter, “ minsan, approximately Although people’s pattern. kahit hindi pa 4 diapers a day, patterns of urination are naman puno ang which is highly individual, kanyang diaper, replaced even if most people void pinapatanggal na it is not yet full, about 5 to 6 times niya kasi naiirita because the a day. daw siya. Kaya patient feels pinapalitan na lang irritated The frequency of naming agad ng wearing the defecation I highly individual, varying bago kapag gusto diaper. from several times na niyang palitan.” per day to two or three times per week. The amount defecated also varies from person to person. (Kozier, Fundamentals of
  • Nursing, 8th edition)Exercise The client’s The client’s The patients To exercise exercise activities are exercise is regularly is to keep includes limited since he limited because one’s body to its needs bed rest for best optimal state. walking.He said, of the need for his recovery. Exercising could “madalang lan However, proper bed rest. But to make a person feel ako mag positioning maintain good rejuvenated and exercise medyo (usually every 2 blood give more energy. busy din kasi hours) is advised circulation, he This is a part of talaga sa as well as range of is advised to do Maslow’s trabaho, at pag motion exercises to range of motion Physiologic Needs. maintain good di naman ako and change of blood circulation. Limitations to busy mas gusto position every 2 movement may be kong makasama The client hours. medically ang pamilya ko.” verbalized: prescribed for  nahihirapan some health akong problems. Bed rest gumalaw-galaw may be the ngayon dahil therapeutic choice nanghihina ang for certain clients. katawan ko (Kozier, tsaka medyo Fundamentals of masakit kapag Nursing, 8th ginagalaw ko edition) ang mga paa ko. Kapag nagpapalit ako ng posisyon, dahan dahan lang ang galaw ko tsaka tinutulungan naman ako ng anak ko o kaya yung nurse dito.”  Limited range of motion  Limited ability to perform gross motor
  • skills Slowed movementHygiene The client takes Since the client is During Personal hygiene is a bath every day on complete bed hospitalization, the self-care by and practice rest, bathing which the patient is which people attend to such good hygiene requires sufficient not able to take functions as practices mobility is a bath. But to bathing, toieting, restricted. maintain his general body However, his hygiene, his hygiene, and daughter or other family does grooming. Hygiene family members do sponge bath on is a highly personal sponge bath to him him. matter determined by individual regularly. values and practices. (Kozier, Fundamentals of Nursing, 8th edition)Substance The client’s has Not applicable The client does Any substanceUse no bad vices. since the client is not use any abused by a person hospitalized and substance. could trigger an illness of a client. continuous Maslow said that monitoring of her overuse of any condition is substance makes a necessary. person susceptible to the agents around that could cause disease. (Kozier, Fundamentals of Nursing, 8th edition)Sleep and The client’s Because of some The client;s Sleep is a basicRest sleeping pattern factors like lighting sleeping human need; it is a is good. He and health care pattern was universal providers coming biological process usually sleeps change because in and out for their common to all 6-8 hours, continuous nursing of being people. We require continuous and care to the patient, confined in the sleep for many
  • with no his sleep pattern is hospital. He is reasons: to cope interruptions or usually interrupted disturbed by with daily stresses, difficulties. He and disturbed. He the lights in the to prevent fatigue, sleeps for only 3-5 to conserve verbalized, room and hours. He energy, to restore “maayos ang verbalized, “ hindi monitoring of the mind and body, pagtulog ko maayos ang the nurses. ad to enjoy life noon. Tuloy- pagtulog ko dito more fully. It is tuloy siya tsaka kasi minsan vital for not only di naman ako nasisilaw ako sa optimal pagising-gising ilaw. Kaya hindi psychological ako nakakatulog ng functioning as the o naiistorbo.” maayos.” rate of healing of damaged tissue is  Restless greatest during  Low and sleep. slowed voice  Slightly The absence of lethargic usual stimuli or the presence of unfamiliar stimuli can prevent people from sleeping. Hospital evironments can be quite noisy, and special care needs to be taken to reduce noise in the hallways and nursing care units. (Kozier, B. et.al., Fundamentals of Nursing, 8th edition)II. Nursing care plan a. Problem identification Nursing Problems Cues Justification IdentifiedImpaired physical S> ABC: The problem affects the
  • mobility related to The client verbalized: airway, breathing and circulation.decreased muscle  nahihirapan akongMaslow’s Hierarchy of needs: Thestrength, gumalaw-galaw ngayon problem affects the physiologicpain/discomfort as dahil nanghihina ang needs specifically the need for bedmanifested by report katawan ko tsaka medyo rest as well as the safety andof pain/discomfort masakit kapag ginagalaw security since the client hason movement, ko ang mga paa ko. Kapagdecreased muscle strength.limited range of nagpapalit ako ngUrgency: The problem is not a lifemotion, slowed posisyon, dahan dahan threatening situation, however,movement lang ang galaw ko tsaka supportive care and assistance tinutulungan naman ako from the family members and theSuggested Functional ng anak ko o kaya yung health care providers specially theLevel Classification: nurse dito.” physical therapists are necessary and of great help so that the patient2- Requires help O> will be able to have goodfrom another person  Limited range of motion circulation, restore her musclefor assistance  Limited ability to perform strength, improve muscle tone and gross motor skills prevent further complications or Slowed movement injury. Proper positioning usually every 2 hours is also indicated for the patient in order to promote good circulation to the body as well as to prevent bed sores. (Client) Resources: Money is needed for maintaining his medications and treatments such as physical therapist that will assist him in range of motion and leg exercises. Time: The time is needed for the patient will personally engaged him in doing these exercises and therapies. Manpower: This is also needed if the patient needs assistance, for example, by a family member. (Nurse) Skills: Available Knowledge: Available Time: AvailableSleep deprivation S> ABC: The problem does not affectrelated to  The client admitted that the airway, breathing anduncomfortable sleep because of some factors circulation.environment as like lighting and health Maslow’s Hierarchy of needs: Themanifested by care providers coming in problem affects the physiologic
  • restlessness and out for continuous needs specifically the need for rest nursing care, his sleep and sleep. pattern is usually Urgency: The problem is not a life interrupted and threatening situation, however, disturbed. He sleeps for sufficient and adequate sleep is only 3-5 hours. He needed in order for the client to uttered, “hindi maayos acquire complete rest that is ang pagtulog ko dito kasi necessary for maintaining good minsan nasisilaw ako sa health. ilaw. Kaya hindi ako (Client) nakakatulog ng maayos.” Resources: Money is not needed; however, proper environmental O> conditions should be  Restless altered/improved in order for the  Low and slowed voice client to acquire good sleep.  Slightly lethargic Lighting and ventilation should be improved since these are factors that somehow affect the sleeping pattern of the client. Time: Adequate time is needed since the client should gain an enough hours of sleep. Man power: N/A (Nurse) Skills- Available Knowledge- Available Time- AvailableImbalanced S> ABC: The problem does not affectNutrition: less than The client verbalized: the airway, breathing andbody requirements  “konti lang ang kinakain circulation.related to inability to ko kasi sumasakit ang Maslow’s Hierarchy of needs: Thedigest food/absorb tiyan ko at kapag madami problem affects the physiologicnutrients as ako kinain, sinusuka ko needs specifically the need for foodmanifested by lack of naman. Kaya konti lang and water.interest in food; ang sinusubo ko kasi Urgency: The problem is not a lifeperceived inability to madali akong masuka. threatening situation; however, thedigest food; tsaka kung minsan wala client needs to attend to his needsabdominal pain; akong ganang kumain. by following the doctor’s orderweakness of muscles Medyo hirap ding akong including the type of diet. Herequired for lumunok at ngumuya should eat the right type andswallowing or kaya madalas puro prutas amount of foods in order for him tomastication na lang ang kinakain ko, maintain good health and be able to tulad ng ubas at orange.” regain his strength.  According to his (Client) daughter, he eats only Resources: Money is needed for
  • 1/2cup of rice and his continuous medication and refuses to eat more hospitalization that includes the because of the discomfort different interventions done to him that he feels. by his health care providers.  He said he prefers to eat Time: Time is needed in order to fruits rather than eating a acquire the full willingness of the meal (consisting of rice, client to cooperate with the health fish and veggies) care team and follow their advices. especially after taking his Man power: The client needs other medications because he is people (example, a family member) easily irritated by the to assist him in eating his foods; medications. especially since he is resting on bed. O> (Nurse)  Lack of interest in food Skills- Available  Prefers eating fruits Knowledge- Available rather than a meal Time- Available b. Nursing care plan NURSING GOAL/ EVALUA- CUES ANALY-SIS NURSING INTERVENTIONS RATIONALE DIAGNOSIS OBJECTIVE TIONS: Impaired Limitat Goal: Instruct in use of side For position GoalThe physical ion in After 8 rails, overhead changes wasclient mobility indepe hours trapeze, roller pads. /transfers. met.verbali related of Client ndent,zed: to nursing Support affected To maintain wasnahihir decrease purpos interve body part/joints position of able toapan d muscle eful ntion, using pillows/rolls, function and demonsakong strength, physic the foot supports/shoes, reduce risk of trategumala pain/dis al client air mattress, water pressure behaviow- comfort movem will be bed, etc. ulcers. rs thatgalaw as ent of able to enablengayon manifest demons Provide regular skin To maintain resump thedahil ed by trate care. skin integrity. tion ofnanghi report of body behavio activitiehina pain/dis or of rs that Observe movement To note any s.ang comfort one or enable when client is incongruenciekatawa on more resump unaware of s with reportsn ko moveme extrem tion of observation. of abilities.tsaka nt, ities. activitiemedyo limited s. Administer To permit Goal
  • masaki range of medications prior to maximal wast kapag motion, Objecti activity as needed for effort/involve met.ginagal slowed ves: pain relief. ment in Clientaw ko moveme After 30 activity. wasang nt minutes able tomga of Schedule activities To reduce identifypaa ko. Suggeste health with adequate rest fatigue. ways onKapag d teachin periods during the how tonagpap Function g, the day. preventalit ako al Level client furtherng Classifica will be Identify energy- Limits fatigue, complicposisy tion: able to: conserving maximizing ations.on, - techniques for ADLs. participation. Goaldahan 2- Identify wasdahan Requires ways on met.lang help how to Consult with To develop Clientang prevent physical/occupation individual was fromgalaw further al therapist, as exercise/mobi able toko another complic indicated. lity program identifytsaka person ations. and identify andtinutul for - appropriate demonsungan assistanc Identify mobility tratenaman e and devices. therapeako ng demons uticanak trate Encourage adequate Promotes well- waysko o therape intake of being and thatkaya utic fluids/nutritious maximizes willyung techniq foods. energy helpnurse ues that production. alleviatdito.” will e help conditioO: alleviat Note Feelings of n.Limite e emotional/behaviora frustration/po Goald conditio l responses to werlessness wasrange n. problems of may impede met.of - immobility. attainment of Clientmotion Verbali goals.Limite ze wasd appreci able toability ation Encourage Enhances self- verbalizto and participation in self- concept and eperfor willingn care, sense of apprecim ess to occupational/diversi independence. ationgross coopera onal/recreational andmotor te with activities. willingn
  • skills the ess toSlowed nterven Encourage client’s Enhances cooperamove tion. involvement in commitment te withment decision making as to plan, the much as possible. optimizing outcomes. interve ntion. c. Discharge planning Medications The client should be closely monitored in complying in his therapy and medications which are: Ketosteril 1tab TID Melatonin 3mg 1cap at hs Digoxin 0.25mg 1tab OD Folic acid 1cap OD Lozacar 1tab OD Sulodexide 250g 1 tab BID Exercise Deep breathing exercise sitting up in bed, supported by pillows or out in a chair. Take a deep breath in through the nose, hold for at least 3-5 seconds and then exhale the air to a pursed lip. Walking to improve circulation When in bed rest, practices turning the client in different position/side at least every 2 hours. And try to exercise the extremities by simply moving/lifting it. Treatment Treatment of the underlying disorders may help prevent or delay development of chronic renal failure. Diabetics should control blood sugar and blood pressure closely and should refrain from smoking. Blood transfusions or medications such as iron and erythropoietin supplements may be needed to control anemia. Dialysis or kidney transplant may eventually be needed. Health Teachings Urinate when the urge occurs or at least every 2-4 hours during the day.
  • It is advisable to have an output of 2.5 to 3 liter/day by appropriate increase in water intake if the patient can tolerate it. Avoid strenuous activity to reduce fatigue. Out-patient As an outpatient, medications that are given should be taken regularly for treatment even when advised to be home. Follow-up checkups must be needed depends on the physicians advice. Diet Sodium--Salt has to be restricted if edema, congestive cardiac failure and hypertension are present Potassium intake has to be restricted in order to avoid hyperkalemia. (Certain fruits, chocolate, milk, vegetable and salt are rich sources of potassium) Adequate calories have to be provided by a diet containing carbohydrate and fat. Hyper phosphatemia can be prevented by giving diet low in phosphate. Milk and dairy products, which are rich in phosphorus, are to be avoided. Dietary supplement of calcium together with vitamin D have to be given to elevate calcium level and abolish symptoms of hypocalcaemia.Spiritual Advise Encourage the patient to pray for his fast recovery.