ASSESSMENT

Subjective/Objective Cues

STATEMENT OF THE PROBLEM

Nursing Diagnosis

PLANNING
Long Term Goal/Short Term Goal

NURSING ACTION
Nursing Interventions with Rationale Independent, Dependent, Interdependent

OUTCOME

Subjective: Namamanhid katawan ko at para akong lumulutang. Objective: *With IVF PLR 1L *Drowsy *Grade 3 Muscle weakness *Irritable (changing positions frequently)

Altered comfort related to numbness of body Definition: Perceived lack of ease, relief, and transcendence in physical, psychological, spiritual, environmental and social dimensions. Etiology: Disorders affecting the peripheral elements of the nervous system are the more common causes of numbness and tingling. They also tend to be associated with more localized symptoms and sharper borders between normal and abnormal sensation, thereby causing discomfort. Background Theory: Peripheral neuropathy is damage to nerves of the peripheral nervous system, caused by hypotension thereby triggering the numbness sensation of the client, thus altering comfort.

Short term goal:

At the end of 5 hours nursing intervention, client will be able to:

*Feel decreased numbness of body *Increase comfort as evidenced by: continuous sleeping, increase muscle grade weakness to atleast grade 4 and remain in one position atleast for 15mns.

Independent: *Provide bedside care R: Promotion of environment increases comfort. *Repositioned client to supine with feet slightly elevated. R: Elevation of lower extremities promotes circulation thereby decreasing numbness promoting comfort. *Provided health teachings about diet- intake of low salt and low fat. R: Health teaching is the primary tool for disease prevention, cure and rehabilitation.

At the end of 5 hours nursing intervention, goal was met as evidenced by: Subjective: Hindi na gaano namamanhid katawan ko. Objective: *Slept continuously for an hour. *Muscle grade weakness increase to grade 4. *Alert wen being talked to.

Dependent: *Administer Ranitidine as prescribed. R: Ranitidine prevents gastric acid secretion thereby preventing occurrence of epigastric pain due to antibiotics thus promoting comfort.

Students Special Learning For me, my special learning on this exposure is the reverse disease of hypertension which in the case of my client happened to be hypotension now , this is special for me because my father has hypertension and I dont want him to experience this, and of course because most of the Filipinos today suffer from hypertension and and as a student nurse I must know what to do and how to handle this kind of situation. I would want to know more about this. Clinical Instructors Remark:

Prepared By: Diana Laura Lei V. De Leon

Clinical Instructor: Kristian Dior Solina RN,MAN

Date: September 12, 2013