NCP

Assessment S: Ok naman naman ako kaya lang dikitun ako mag kakan as verbalized by the pt. O: Slightly Pale in appearance Decreased subcutaneous fats Poor skin turgor Weak in appearance Limited ROM Lack of  appetite BP=100/70 T=36.7 P=90 R=18 y

y

y

y

y y

y

Nursing Diagnosis Imbalanced Nutrition: Less than body requirements r/t inadequate food intake

Rationale Malnutrition maybe a consequence of the pts lifestyle, lack of knowledge about adequate nutrition and its role in health maintenance, lack of  resources, lack of appetite.

Outcome Identification After 8 hours of  nursing intervention the pt will verbalized understanding the importance of proper nutrition and exercise

Intervention

Rationale

v/s taken and recorded

*in order to get  the baseline data

I and O monitored

* Determination of  amount of  amount of  fluid   fluid  intake and output. *to know the  perception of client 

Encourage verbalization of  feelings

Evaluation y

y

Kept safe and comfortable in bed

*in order to avoid  accidents

y

Reinforced adequate rest period

*to regain energy  and to avoid  straining

y

Referred to *Dietitians have a dietitian for greater  further understanding of  assessment and the nutritional  recommendations value of foods and  regarding food may be helpful in preferences and assessing specific nutritional ethnic or cultural  support  foods Facilitated proper position while

*Elevating the head of bed 30

y

Patient verbalize understanding of importance of balance nutrition Demonstrates behavior changes to regain appropriate weight Able to ingest increase fluid intake and foods rich in vitamins. Able to consume Recommende d Daily Allowances (RDA) Still pale in appearance, poor skin torpor.

eating and observed SAP.

Provided good oral hygiene

Provide companionship during mealtime.

Encouraged to increase fluid intake at least 8 glasses of water a day and eat foods reach in protein, carbohydrates, and vitamins.

degrees aids in swallowing and  reduces risk of  aspiration. *in order to give comfort to the patient through feeling clean and fresh * Attention to the social aspects of  eating is important  in both the hospital and home settings. * Supplemental  nutrition, to enhance wound  healing and regain energy.

Discourage beverages that are caffeinated or carbonated.

* These may  decrease appetite and lead to early  satiety.

Encouraged ambulation and passive Rom

* Metabolism and  utilization of  nutrients are enhanced by  activity.

Health

teaching rendered: * Foods high in The basic calories and  four food groups, as  protein that will   promote weight  well as gain and nitrogen the need balance for specific minerals or vitamins. y

Assessment S:Mayo pa si aki ko na may dara kang pang linig dgdi ska pang ribay sa colostomy bag as verbalized by the pt.

Nursing Diagnosis Risk for infection r/t post op surgery

Rationale Inadequate natural defense mechanisms to protect from the inevitable injuries

O: y

y

y

y

Weak

in appearance Poor muscle tone With colostomy bag With JP drainage draining well.

Breaks in the integument, the bodys first line of  defenses (surgical opening)

Pts immune system cannot combat the invading organism adequately

Outcome Identification After 8 hours of  nursing intervention the pt will understand ways on preventing infection and to reduce further complication

Intervention

Rationale

v/s taken and recorded

*to get baseline data

Maintain clean technique in cleaning and changing the colostomy bag

*to avoid  invasion of  microorganisms

Instructed to perform passive ROM

*To promote  proper circulation

* This reduces the number of  organisms in  patients environment and  restricts visitation by  individuals with any type of  infection to reduce the transmission of   pathogens to the  patient at risk for  infection. Observed for any *to assess the untoward s/sx such signs of infection as redness, swelling, increased

Evaluation y

y

Instructed client to limit visitors

y

y

Patient verbalized understand ways on preventing infection and ways to reduce further complication. Able to demonstrate proper colostomy care and hand washing Verbalized understanding the importance of  proper hygiene and identified s/sx of infection. Still weak in appearance

pain, or purulent drainage at incisions, injured sites. Encourage intake of protein- and calorie-rich foods.

*This maintains optimal  nutritional  status. Encourage *These measures coughing and deep reduce stasis of  breathing; consider secretions in the use of incentive lungs and  spirometer. bronchial tree. When stasis occurs,  pathogens can cause upper  respiratory  infections, including  pneumonia. Health teaching given: *To lessen Teach patient and microorganisms; Patients and  significant caregivers can others to spread infection wash  from one part of  hands the body to often, another, as well  especially as pick up surface after  pathogens; hand  toileting, y

y

y

before meals, and before and after administeri ng selfcare.

washing reduces these risks.

Teach patient the signs and symptoms of  infection, and when to report these to the physician or nurse. Demonstra tes steps in applying colostomy, identified equipment s needed with colostomy care and allow return demonstra tion.

*To give immediate intervention

*to provide the pt independence in caring for the colostomy

y

Reviewed importance of proper hygiene

* To lessen microorganisms

Assessment S: O: y

Weakness

y

Lack

y

y

of  motivation With discomfort due to presence of  colostomy and JP drain Impaired transfer ability

Nursing Diagnosis Self Care Deficit r/t transient limitations due to presence of  colostomy and JP drain.

Rationale Result of  progressive deterioration that erodes the individuals ability or willingness to perform the activities required to care for himself or herself.

Patient with physical limitations due to colostomy and JP drain this is a hindrance to perform normal personal function.

Outcome Identification After 8 hours of  nursing intervention the pt will demonstrates: a. Patient safely perform s (to maximu m ability) self-care activitie s. b. Optimiz

ing the autono my and indepe ndence of the patient. c.

Perform self care activitie s within level of  own ability d. Demons

Intervention

Rationale

Assessed ability to carry out ADLs (on regular basis and determine the aspects of self  care that are problematic to the patient.

*The patient may  only require assistance with some self-care measures.

y

y

Assessed patients *This increases need for assistive independence in devices.  ADLs  performance. Identified * These support  preferences for  patients food, personal individual and  care items, and  personal  other things.  preferences. Assisted patient in accepting necessary amount of dependence.

Evaluation

* Patient may  need to grieve before accepting that dependence is possible.

Set short-ranged * Assisting the goals with patient.  patient to set  realistic goals will  decrease  frustration. Encouraged *An appropriate independence, level of assistive

y

Pt was able to demonstrate increased ability to dress/groom self and perform ADL. Still weak in appearance Slow walking

trate ability to cope with the necessit y of  having someon e else assist him/her in perform ing the task.

but intervene when patient cannot perform.

Provided positive reinforcement for all activities attempted; note partial achievements.

care can prevent  injury with activities without  causing  frustration. *This provides the  patient with an external source of   positive reinforcement.

Ensured that patient wears dentures and eyeglasses if  needed.

*Deficits may be exaggerated if  other senses or  strengths are not   functioning optimally. Provided privacy *Patients may  during dressing. take longer to dress and may be  fearful of breaches in privacy. Encouraged use of  *This ensures clothing one size easier dressing larger. and comfort.

Maintained privacy during bathing as appropriate. Assist edpatient with care of 

*The need for   privacy is  fundamental for  most patients. *Patients may  require podiatric care to prevent 

fingernails and toenails as required.

injury to feet  during nail  trimming or  because special  implements are required to cut  nails. Provide dprivacy *Lack of privacy  while patient is may inhibit the toileting.  patients ability to evacuate bowel  and bladder  Assisted patient in *Clothing that is removing or difficult to get in replacing and out of may  necessary compromise a clothing.  patients ability to be continent. Teached family to * This foster demonstrates independence and caring and  to intervene if the concern but does patient becomes not interfere with fatigued, is unable  patients efforts to to perform task, achieve or becomes independence. excessively frustrated.