Individual case pres.docx

7/30/2019 Individual case pres.docx

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BULACAN STATE UNIVERSITY

Mojon, City of Malolos, Bulacan

COLLEGE OF NURSING

A Case Study of Ms.ER,

Dengue Fever SyndromeSubmitted By:

Pescador, John Robert A.

In Partial Fulfillment of the Requirements in NCM 103RLE

Ospital ng Guiguinto

Female Medical Ward

4th

Rotation

(September 10, 2012)

Submitted to:Mr. Rogie Abalos


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I. NURSING ASSESSMENT

A. Biographic Data

Name: Ms. ER Marital Status: Single

Address: Poblacion Guiguinto, Bulacan Occupation: Garments Factory Worker

Age: 20 years old Religious Orientation: Catholic

Sex: Female Usual Source of Medical Care: Hospital

Race: Filipino

B. Chief Complaint

3 Days of High Fever, Dizziness and Vomiting, Appearance of Rashes after Fever subsides


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C. History of Present Illness

On the morning of September 3, 2012, client stated that she started feeling hot and dizzy. She stated she always vomit every after meals. As the day

goes by, the client felt that she was weakening. Feared that her daughters condition would worsen, the clients mother brought the client to a faith healer, her

grandmother. After different ceremonies and tapal-tapal, the clients condition did not improve. The client was brought to Ospital ng Guiguinto on September 6,

2012 for the check up. She was not admitted after the check up because her diagnosis was only Flu. But the following day, the clients rashes started to appear. She

was rushed again to the hospital and had been diagnosed of DFS (Dengue Fever Syndrome).

D. Past History of Illness

The client stated that she did not have any severe illnesses that would render her impaired. She said that simple sickness such as coughs and colds

and some episodes of fever and flu are common diseases that she acquires. According to the clients mother, the client received complete immunizations when she

was just a baby. The client stated that she remembered being vaccinated when she was in elementary but she didnt know what i t was for.

E. Functional Health Pattern (Gordons Approach)

Health Perception and Health Management PatternWhen asked about clients perception of her health, she answered okay naman ako kahit papano but when she was hospitalized she stated ang

hirap magkasakit. When asked to rate her health on a scale of 1 to 10 with 10 being the highest and 1 being the lowest. Befo re she was hospitalized, she rated 8.

But when she was admitted, she rated it 5. Whe n asked what she does to prevent sickness she said pahinga lang, tapos inom ng maraming tubig. Vitamins narin.

She does not smoke or use drugs of any kind but she does drink when kapag napapagtripan lang naming magbabarkada, as verbal ized by the client. But she said

that it just happens once a month and she drinks within her limits. Client always make sure to follow different orders of the physician but when it comes to drug

compliance, she sometimes cannot comply because of lack of funds.


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B. Nutritional and Metabolic Pattern

This is the clients 3 day diet recall prior to hospitalization and 3 days during hospitalization:

PRIOR TO HOSPITALIZATION

09.04.12 09.05.12 09.06.12

BREAKFAST 1 BOWL OFPORRIDGE

120ml OF WATER 1 BOWL OF

PORRIDGE


PORRIDGE

120ml OF WATER

LUNCH 1 CUP OF RICE 1 SERVING OF

SINIGANG NABABOY

1 PIECE OF BANANA 120ml OF WATER

1 CUP OF RICE 1 SERVING OF

NILAGANG BABOY 1 PIECE BANANA 120ml OF WATER


SINIGANG NABANGUS

120ml OF WATER

DINNER 1 BOWL OFPORRIDGE

120ml OF WATER

1 BOWL OFPORRIDGE

120ml OF WATER

1 BOWL OFPORRIDGE

120 ml OF WATER


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DURING HOSPITALIZATION

09.07.12 09.08.12 09.09.12

BREAKFAST 1 PIECE PANDESAL 240ml OF WATER 1 BOWL OFPORRIDGE


PORRIDGE

240ml OF WATER

LUNCH 1 CUP OF RICE 1 SERVING OF

SINIGANG NA

BABOY

1 PIECE OF BANANA 240ml OF WATER


PAKSIW NA BANGUS

1 PIECE BANANA 240ml OF WATER


SINIGANG NA

BANGUS

240ml OF WATER

DINNER 3 PIECES OFPANDESAL


PORRIDGE

240ml OF WATER 1 CUP OF RICE 1 SERVING OF

ADOBONG BABOY

240 ml OF WATER

When asked about her typical food intake and preferences, she stated that she is not picky of food and usually eats mixed variants. According to the

client, she only drinks water at around 4 to 5 glasses only a day, kala kalahati kasi ako uminom ng tubig as verbalized by the client. She said that every after

meals, she would always want a bar of chocolate or any chocolate. masarap kasing kumain ng chocolate pagkatapos kumain, parang dessert as stated by the

client.before hospitalization, she doesnt follow any diet whatsoever but now she is following a diet prohibiting dark colored foods or EDCF diet. When asked about

her skin, she said ok naman, nung nagkarashes lang ako sobrang kati, sa likod pa karamihan. She drinks coffee 3 times a day, one in the morning, in mid morning

and last at 5 oclock afternoon. Client only let her wounds or scrape to heal, not applying ointments or any patches. She has no dentures and dental checkups. She


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doesnt experience scalp itching but she suffered from louse infestation during elementary but it disappeared when entering high school. She doesnt have any issues

regarding hot or cold foods but she prefers hot foods. Deformation of nails or feet is not noted and the client also stated that she didnt experience any deformation.

C. Elimination Pattern

A. BOWEL ELIMINATION PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION

FREQUENCY 1 time per day Did not pass stool for 3 days

CHARACTERISTICS Usually Brown, firm Brown, soft

DISCOMFORT No discomfort No discomfort

B. URINARY ELIMINATION PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION

FREQUENCY Usually 3-4 times a day (normal to client) Usually 6-7 times a day

CHARACTERISTICS Light Yellow to yellow, aromatic odour Straw colored(clear), aromatic odour

DISCOMFORT No discomfort No discomfort

PROBLEM IN CONTROL None None

D. Activity-Exercise Pattern

According to the client, wala nga akong ginagawa sa bahay,aalis ako ng alas sais dadating ako mga 10 na ng gabi kaya wala ko nagagawa. Since her

workplace is near to their house, she always takes a way on her way to her work. She considers this as a form of exercise since she doesnt have time at all toexercise because she said that even though it is Sunday, she still works. She sleeps during leisure hours because she said that her work is very tiring.


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E. Sleep-Rest Pattern

Before hospitalization the client sleeps for 5-6 hours only because she said that she usually sleeps at around 11pm and wakes up at 5am because she

needs to get ready to go to work. But the client said that when her schedule changes, her sleep pattern sometimes is disturbed especially when she is working at

graveyard shifts. During hospitalization, she said that her sleep was frequently interrupted because of test that needs to be done thus disturbing her sleep.Eventhough this happens, the client said that her quality of sleep is tolerable.

F. Cognitive-Perceptual Pattern

According to the client, she doesnt experience any problems with her sight or the eyes but she is yet to visit the opthalmolo gist ang get her eyes

examined. She stated that she also doesnt have problems with her hearing despite working in a factory. She can taste and smell the foods that she is eating.

G. Self-Perception and Self-Concept Pattern

When asked how does the client describe herself, she stated, Okay naman, mahirap nga lang talaga magkasakit kasi una wala kanang

kita,nagagastusan ka pa kasi sobrang mamahal ngayon ng gamot as verbalized by the client. She doesnt notice any body changes or weight loss. Payat na talaga

ko simula nung bata pa ko as stated by the client. Her source of strength is her family.

H. Role-Relationship Pattern

The client belongs to a nuclear family because she is living with her mother along with her younger sister and one of her older brother. When

confronted with different family problems, she said that she trust God to wipe these problems away and they always talk if there are problems within the family. She

works so she can contribute to their familys expenses and also save up so that she can finish her studies so that she can provide for her family. If in a bad mood,she

relaxes by taking a nap or watching the television. Medyo marami naman kaming magbabarkada kaya hindi boring as stated by the client.


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I. Sexuality-Reproductive Pattern

The client had her menarche at the age of 13. When asked if she is in favour of contraceptives despite of not being pregnant, she answered yes

because she said that marami ng pilino ngayon kaya kelangan naring magpigil, kaya nga nilikha yun para gamitin eh. She said she wants to have kids at the right

time and at the right moment.

J. Coping Stress-Tolerance Pattern

As a working individual, she said it is natural for her to experience stress. That is why she seeks leisure with sleeping, having fun with friends and

also having quality time with her family. When asked what is the biggest change in her life, she answered it when she graduated high school because finally she

finished high school even though she frequently stop because of financial problem.

K. Value Belief-Pattern

The client stated that even though she doesnt usually get the things she wants in life, she does not complain about it, she is usually contented on

what she have. The most important thing in the clients life is her family. She stated that she is not a religious person. She does attend Sunday mass every week. She

noted that she prays every night and every morning after getting up from her bed. She also shared that she believes in faith healers and albularyos of different kind

because her grandmother is one and also she experienced relief of some sickness when seeking advice of faith healer.


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PHYSICAL ASSESSMENT

Date assessed: September 10, 2012

General assessment: conscious and coherentInitial vital signs: T=36.6C, RR=20, BP=100/60, PR=80

Area Assessed Technique Normal Findings Actual Findings EvaluationSkin

Color Inspection Light brown, tanned skin (varyaccording to race)

Light brown skin Normal

Soles and palms Inspection Lighter colored palms, soles Lighter colored palms, soles Normal

Moisture Inspection/Palpation

Skin normally dry Skin normally dry Normal

Temperature Palpation Normally warm Normally warm Normal

Texture Palpation Smooth and soft Smooth and soft Normal

Turgor Palpation Skin snaps back immediately Skin snaps back immediately Normal

Skin appendages

a. Nails

Inspection Transparent, smooth and convex Transparent, smooth and convex NormalNail beds Inspection Pinkish Pale Due to decreased blood flow

Nail base Inspection Firm Firm Normal

Capillary refill Inspection/ Palpation

White color of nail bed underpressure should return to pink

within 2-3 seconds

Returns within 2-3 seconds Normal

b. HairDistribution Inspection Evenly distributed Evenly distributed Normal

Color Inspection Black Black Normal

Texture Inspection/ Palpation Smooth Smooth Normal

Eyes

Eyes Inspection Parallel to each other Parallel to each other NormalVisual Acuity Inspection (penlight) PERRLA- Pupils equally roundreact to light and accommodation

PERRLA- Pupils equally roundreact to light and accommodation

Normal


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Eyebrows Inspection Symmetrical in size, extension, hairtexture and movement

Symmetrical in size, extension, hairtexture and movement

Normal

Eyelashes Inspection Distributed evenly and curvedoutward

Distributed evenly and curvedoutward

Normal

Eyelids Inspection Same color as the skin

Blinks involuntarily and bilaterallyup to 20 times per minute

Do not cover the pupil and thesclera, lids normally close

symmetrically

Same color as the skin

Blinks involuntarily and bilaterallyup to 18 times per minute

Do not cover the pupil and thesclera, lids normally close

symmetrically

Normal

Normal

Normal

Conjunctiva Inspection Transparent with light pink color Transparent with light pink color Normal

Sclera Inspection Color is white Color is white Normal

Cornea Inspection Transparent, shiny Transparent, shiny Normal

Pupils Inspection Black, constrict briskly Black, constrict briskly Normal

Iris Inspection Clearly visible Clearly visible Normal

EarsEar canal opening Inspection Free of lesions, discharge of

inflammation

Canal walls pink

Free of lesions, discharge of

inflammation

Canal walls pink

Normal

Normal

Hearing Acuity Inspection Client normally hears words when

whispered

Client normally hears words when

whispered Normal

Nose

Shape, size and skincolor

Inspection Smooth, symmetric with same coloras the face

Smooth, symmetric with same coloras the face Normal

Nares Inspection Oval, symmetric and withoutdischarge

Oval, symmetric and withoutdischarge Normal


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Mouth and

Pharynx

Lips Inspection Pink, moist symmetric Light pink, dry, symmetric Lack of fluid intake

Buccal mucosa Inspection Glistening pink soft moist Glistening pink soft moist Normal

Gums Inspection Slightly pink color, moist and

tightly fit against each tooth

Slightly pink color, moist and tightly

fit against each tooth NormalTongue Inspection Moist, slightly rough on dorsal

surface medium or dull red

Moist, slightly rough on dorsal

surface medium or dull red Normal

Teeth Inspection Firmly set, shiny Firmly set, shiny

With tooth decay

Normal

Hard and soft palate Inspection Hard palate- dome-shapedSoft Palate- light pink

Hard palate- dome-shapedSoft Palate- light pink Normal

Neck

Symmetry of neckmuscles, alignment

of trachea

InspectionNeck is slightly hyper extended,without masses or asymmetry

Neck is slightly hyper extended,without masses or asymmetry Normal

Neck ROM Inspection Neck moves freely, without

discomfort

Neck moves freely, without

discomfort

Normal

Thyroid gland Palpation Rises freely with swallowing Rises freely with swallowing Normal

Thorax and Lungs Auscultation Clear breath sounds Clear breath sounds Normal

Abdomen

Bowel sounds

Abdominal

distention

Inspection

Auscultation

Palpation

Skin same color with the rest of the

body

Clicks or gurling sounds occur

irregularly and range from 5-35 perminute

No distention noted

Skin same color with the rest of the

body

Clicks or gurgling sounds occur

irregularly and range from 20 perminuteComplaint of pain, abdomen is

distended

Normal

Normal

Deviation from normal

Extremities


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Symmetry

Skin color

Hair distribution

Skin Temperature

Presence of lesion

ROM

Inspection

Inspection

Inspection

Palpation

Inspection

Inspection

Symmetrical

Same with the color of other parts

of the body

Evenly distributed

Warm to touch

No lesions

Moves freely without discomfort

Symmetrical

Same with the color of other parts of

the body

Evenly distributed

Warm to touch

No lesions

Able to move but with assistance

Normal

Normal

Normal

Normal

Normal

Due to body weakness

Level of

consciousness

Inspection Fully conscious, respond toquestions quickly, perceptive ofevents

Fully conscious, respond toquestions quickly perceptive ofevents

Normal

Behavior and

appearance

Inspection Makes eye contact with examiner,

hyperactive expresses feelings with

response to the situation

Makes eye contact with examiner,

hyperactive expresses feelings with

response to the situation Normal


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II. STUDY OF THE DISEASE

WHAT IS DENGUE FEVER SYNDROME?

-Dengue fever is a disease caused by a family of viruses that are transmitted by mosquitoes. It is an acute illness of suddenonset that usually follows a benign course with symptoms such as headache, fever, exhaustion, severe muscle and joint pain, swollen glands

(lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristicof dengue. Other signs of dengue fever include bleeding gums, severe pain behind the eyes, and red palms and soles.

Dengue (pronounced DENG-gay) can affect anyone but tends to be more severe in people with compromised immune systems. Because it is

caused by one of four serotypes of virus, it is possible to get dengue fever multiple times. However, an attack of dengue produces immunityfor a lifetime to that particular serotype to which the patient was exposed.

Dengue goes by other names, including "breakbone" or "dandy fever." Victims of dengue often have contortions due to the intense joint andmuscle pain, hence the name breakbone fever. Slaves in the West Indies who contracted dengue were said to have dandy fever because oftheir postures and gait.

Dengue hemorrhagic feveris a more severe form of the viral illness. Symptoms include headache, fever, rash, and evidence of hemorrhage

in the body. Petechiae (small red or purple splotches or blisters under the skin), bleeding in the nose orgums, black stools, oreasy bruisingare all possible signs of hemorrhage. This form of dengue fever can be life-threatening and can progress to the most severe form of theillness, dengue shock syndrome.

Dengue fever is a disease caused by a family of viruses that are transmitted by mosquitoes.

Symptoms such as headache, fever, exhaustion, severe joint and muscle pain, swollen glands (lymphadenopathy), and rash. Thepresence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue fever.
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Dengue is prevalent throughout the tropics and subtropics. Outbreaks have occurred recently in the Caribbean, including Puerto Rico,the U.S. Virgin Islands, Cuba, and in Paraguay in South America, and Costa Rica in Central America.

Because dengue fever is caused by a virus, there is no specific medicine or antibiotic to treat it. For typical dengue fever, the treatmentis purely concerned with relief of the symptoms (symptomatic).

The acute phase of the illness with fever and myalgias lasts about one to two weeks. Dengue hemorrhagic fever (DHF) is a specific syndrome that tends to affect children under 10 years of age. It causes abdominal pain,

hemorrhage (bleeding), and circulatory collapse (shock).

The prevention of dengue fever requires control or eradication of the mosquitoes carrying the virus that causes dengue. There is currently no vaccine available for dengue fever.

III. DIAGNOSTIC PROCEDURE / LABORATORY

LABORATORY /

PROCEDURE

DATE ORDERED/

DATE OF RESULTIN

INDICATION/

PURPOSES

NORMAL VALUES ACTUAL VALUES ANALYSIS/

INTERPRETATION

NURSING

RESPONSIBILI(PRIOR, DURINAFTER)

COMPLETE BLOOD

COUNT with PLATELETCOUNT

Date ordered:

September 8, 2012

Date of result:September 9, 2012

This test is used to

evaluate anemia,leukemia, reaction to

inflammation andinfections, peripheral

blood cellularcharacters, State of

hydration and

dehydration,Polycythemia,Hemolytic disease of

WBC - ( 4.510.0 )

RBC( 4.305.80)HCB(123153 )

HCT( 0.3500.440 )

PLT( 150400 )PCT - ( 0 .100 -

0.500 )

WBC- 11.2

RBC- 3.81HCB- 126

HCT- .380PLT- 299

PCT- 194

High

NormalNormal

NormalNormal

Normal

Before: Tell the

about the backgrof the test, how i

done and the posoutcome of the te

Be sure of theidentification of

client to avoid er

during the reportof result.Be aware of the


15/25

the newborn, tomanage chemotherapy

decisions.

information abouhepatitis infectio

and other infectirelated to blood.

During: Avoidcontact with clie

secretions.

After: Make surethe client unders

the outcome/resuAlso to give the r

to the right clienthe right time.


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IV. THE PATIENT AND HER CARE

A. MEDICAL MANAGEMENT

a. IVT, Blood transfusion, Nebulization, total parenteral nutrition, NGT, Oxygen therapy etc.

MEDICAL

MANAGEMENT

DATE ORDERED,

DATE GIVEN/

CHANGED/

DISCONTINUED

GENERAL DESCRIPTION INDICATION/

PURPOSES

CLIENTS

RESPONSE

NURSING

RESPONSIBILITI

(Prior, During, Aft

IVF of PLR 1L for 8 hours@ 31gtts/min

Date Ordered:September 7, 2012

Lactated Ringer's solution isa solution that is isotonic with

blood and intended forintravenous administration. It

may also be givensubcutaneously. Lactated

Ringer's solution is groupedwith intravenous fluids known

as "crystalloids"whichinclude saline and dextrose

solutions (compared to the"colloids" which contain

larger molecules such as

Lactated Ringer'ssolution is often used

for fluid resuscitationafter a blood loss due to

trauma, surgery, or aburn injury. Previously,

it was used to induceurine output in patients

with renal failure.

Client did not developany allergic reactions or

complications duringand after insertion of

the IVF

Prior:

Do not administer unless

isClear and container is

undamaged.

During:

Stay with the client to moclients response

After:

Discard unused portion

Prior:

Check the level of the IVF
http://en.wikipedia.org/wiki/Tonicityhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Intravenous_therapyhttp://en.wikipedia.org/wiki/Subcutaneoushttp://en.wikipedia.org/wiki/Crystalloid_solutionhttp://en.wikipedia.org/wiki/Saline_%28medicine%29http://en.wikipedia.org/wiki/Intravenous_sugar_solutionhttp://en.wikipedia.org/wiki/Colloidhttp://en.wikipedia.org/wiki/Blood_losshttp://en.wikipedia.org/wiki/Physical_traumahttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Burn_injuryhttp://en.wikipedia.org/wiki/Renal_failurehttp://en.wikipedia.org/wiki/Renal_failurehttp://en.wikipedia.org/wiki/Burn_injuryhttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Physical_traumahttp://en.wikipedia.org/wiki/Blood_losshttp://en.wikipedia.org/wiki/Colloidhttp://en.wikipedia.org/wiki/Intravenous_sugar_solutionhttp://en.wikipedia.org/wiki/Saline_%28medicine%29http://en.wikipedia.org/wiki/Crystalloid_solutionhttp://en.wikipedia.org/wiki/Subcutaneoushttp://en.wikipedia.org/wiki/Intravenous_therapyhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Tonicity


17/25

starch or gelatine).. During:Correct solution, medicat

volume.Check and regulate the dr

After:

Monitor patients signs of

infiltration / sluggish flow

b. Drugs

Generic/ Brand Name/

Drug Classification

Date Route of

Administration,Dosage,

Frequency

Mechanisms ofAction

ClientsResponse

Nursing ResponsibilitiesOrdere

d

Taken/

Given

Changed Discontinue

d

Prior During A

1. Paracetamol

Classification :NSAIDS

Sept. 7,

2012

Sept. 7,

2012

September

9, 2012

Per Orem Paracetamol is a

widely used over-the-counter

analgesic (painreliever) andantipyretic (fever

reducer). It iscommonly used forthe relief of fever,

Client did not

develop anyallergy

Determine

history ofprevious

hypersensitivity to penicillinand other drug

allergiesbeforetheraphy is

Advise

patient tomaintain

normal fluidintake while

using this

medication.

Mo

sisup

on.thepr


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2. CelestamineClassification: Anti-

allergics

Sept.7, 2012

Sept. 7,2012

Sept.

8,2012Per Orem

headaches, andother minor aches

and pains, and is amajor ingredient in

numerous cold andflu remedies. In

combination withnon-steroidal anti-

inflammatorydrugs (NSAIDs)

and opioidanalgesics,

paracetamol isused also in the

management ofmore severe pain

(such as cancer orpostoperative

pain).

Celestamine

belongs to thesteroid family and

works byinhibiting the

production ofcompound in the

body causing pain

and inflammation.

Celestamine is

Clients itchinesssubsided

initiated

Determinehistory of

previoushypersensitivi

ty to penicillinand other drug

allergiesbefore

theraphy isinitiated

Advisepatient to

maintainnormal fluid

intake whileusing this

medication

Mosi

supon.

thepr


19/25

administered fortreating many

health conditionswhich includes

allergic reactions,respiratory

problems, skinconditions

c. Diet

TYPE OF DIET

DATE ORDERED,

DATE CHANGED,

DATE

DISCONTINUED

GENERAL

DESCRIPTION

INDICATION/

PURPOSES

SPECIFIC FOOD

TAKEN

CLIENTS

RESPONSE

NURSING

RESPONSIBILITI

EDCF (Except DarkColored Foods)

Date Ordered:September 7, 2012

It is a diet thatwithholds client

eating colored foodsthat might change

stool color.

It is a diet instructedto a client that is for

stool exams foroccult blood. This is

to prevent false

positive result ofhemorrhage.

Client is toleratingthe diet

Ensure that the cliewell nourished andeating at the timeordered by the phy

Make sure that darfoods are not part oclients diet until distopped by the phy


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NURSING CARE PLAN I

ASSESMENT NURSING

DIAGNOSIS

GOAL INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:

Masakit ung tiyan

ko.

Objective :

Palpation ofabdomen; distension

noted

Acute Pain related to

physical agentsmanifested by

abdominal distension

Develop nurse-patient

relationship toestablish rapport.

Client will reportpain is relieved

Client will followpharmacological

treatment

Client willverbalize method

to relieve pain

1.

Establishtherapeutic andfacilitate

relationshipshowing positive

regard for the client.

2. Provide comfortmeasures and also

pharmacologictreatment as ordered

3. Teach client theimportance of

pharmacologiccompliance

4. Render teachingabout different

positioning

technique that helpsin relieving pain

Client may then feel safe todisclose feelings and feelunderstood.

Clients pain sensation willsubside with proper

nonpharma. And pharma.treatments

Promotes clients knowledgeabout compliance and how it

can help in the recovery.

Promotes clients knowledge ofproper positioning techniques

and how it relieves pain.

Goal Met:Was able to develop Nurse- patrelationship and establish rapport

Goal Met:

Client reported relief of pain

Goal Met:

Client followed ordered

pharmacological treatment

Goal Met:

Client verbalized method to relieve

pain


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NURSING CARE PLAN II

ASSESMENT NURSING

DIAGNOSIS


SUBJECTIVE:None

OBJECTIVE:

Client is unable to

perform selfresponsibilities by

herself Ex.

Changing ofclothes

Self Care Deficitrelated tomechanical

restriction

Develop Nurse-patientrelationship to establishrapport.

The client will be able toverbalize the

understanding on the

importance of regularself care.

Identify restrictions and

if possible remove theserestrictions.

Client will be able to

report ease and be able toperform self care

responsibilities.

Review necessity for andbenefits of regular self care

Teach client on ways tocope with said restrictions.

Inspect the different

paraphernalia connected tothe patient

Assist and support with

alternative placements ofrestrictions and allow them

free time away from caresituations to renew

themselves

.

Self care promotes ease infeeling.

This is to motivate clientsperception about these said

restriction and improve their

coping skills

Identifying what causes the

problem is a must

This will promote

rejuvenation and a clearperspective from the client

that she is not confined butfree.

Goal Met:We were able to gain trust or rafrom the client

Goal Met:

Client verbalized the importan

regular self care

Goal Met:

Was able to identify restrictions

Goal Unmet:

Client was able to report ease

resume performing careresponsibilities


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NURSING CARE PLAN III

ASSESMENT NURSING

DIAGNOSIS


SUBJECTIVE:nagigising gising

kasi ako kapag

may nurse nakukuha ng dugo

Disturbed sleeppattern related tobeing interrupted for

therapeutics

Client will verbalizeunderstanding of sleepdisturbance

Client will adjust

lifestyle to accommodate

chronobiological rhythms

Client will report

improvement insleep/rest pattern and

feeling well-rested

Teach client theimportance of sleeping andits regular pattern and how

it affects patients recovery

Suggest changing clients

sleep pattern with the help

of pharmacologicaltechniques and non

pharmacologicaltechniques

Formulate different plan of

care for the client ifpossible

Improvement of clientsknowledge about sleep/rest

pattern.

This is to provide client

with energy and not be

disturbed during times ofspecimen collecting

If possible, client sleeping

pattern will not be changedand instead of disturbances

of regimens, clients qualityof sleep will improve

Goal Met:Client Verbalized understandinsleep disturbance

Goal Met:

Client adjusted to adjusted

lifestyle to accommchronobiological rhythms

Goal Met:

Client reported improvemensleep/rest pattern and feeling

rested


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NURSING CARE PLAN IV

ASSESMENT NURSING

DIAGNOSIS


SUBJECTIVE:minsan hindi

nakakabili ng

gamot kasi mahal

Noncompliance tomedications relatedto insufficient funds

for therapeuticregimen

Client will participate inthe development ofmutually agreeable goals

and treatment plan

Client will verbalize

accurate knowledge of

condition andunderstanding of

treatment regimen

Client will make choices

at level of readinessbased on accurate

information.

Client will demonstrateprogress toward desired

goals

Involve client and SOs informulation of treatmentregimen

Render health teaching

about clients condition

and how treatment regimenis to be rendered and how

costly it is.

Provide client with an

ample time to decide aboutappropriate regimen for

him/her

Assist client to differentpublic assistance and

Government insurance forappropriate loans or

insurance benefits.

This will boost client moralabout his/her involvement inhis/her ways to seek

appropriate health care

Provides proper knowledge

for clients improved

decision making

Client need not to be rushed

for them to choose the mostsuitable therapeutic regimen

for them.

Help from governmentfacilities will be a great

contributor to lessen factorsthat affect compliance

Goal Met:Client participated in development of mutually agre

goals and treatment plan

Goal Met:

Client verbalized cond

accurately and understood treatment regimen for her

Goal Met:

Client demonstrated protowards desired goals


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NURSING CARE PLAN VASSESMENT NURSING

DIAGNOSIS


SUBJECTIVE:hindi pa sakinnaeexplain ng

mabuti ng doctorkung ano na ba ang

lagay ko

DeficientKnowledge aboutown condition

related to incompleteinformation

Client will exhibitincreased interest forown learning

Client will verbalizeunderstanding of

condition/ disease

process and treatment

Perform necessary

procedures correctly andexplain reason why it has

to be done.

Client will initiatenecessary lifestyle

changes and participatein treatment regimen

Gather different learningsource that is easy tounderstand

Teach client about theconcept of proper

knowledge and how

knowledge helps towardsachieving goals

Teach client self care

procedures that arenecessary for recovery

Modify clients lifestyle byformulating appropriate

treatment regimen

For the client to easyunderstand difficult termsand to avoid boredom

The first step of knowledgeis to know the concept first

and apply

Client develops sense of

independence and sense ofresponsibility for

himself/herself

If possible, this is for theclient to easily cope with

changes

Goal Met:Client exhibited increased infor own learning

Goal Met:

Client verbalized condition / diprocess and treatment

Goal Met:

Client performed neceprocedures correctly and expl

reason why such procedures shbe done

Goal Met:

Client initiated necessary life

changes participate in treatregimen


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Documents

Individual case pres.docx