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Assessment Subjective Data Mahal yung gamot ko tsaka iniinom ko lang yun pagsumasa ma o tumataas ung blood pressure

e ko. as verbalized by the patient. Objective data Noncomplianc e to medication Insufficient

Nursing Diagnosis

Rationale Pattern in which a person experiences or is at risk to experience difficulty integrating into daily living a program for treatment of illness and the sequence of illness that meets specific health goals. Individuals experiencing difficulty achieving positive outcomes when it he or she experiences various health problem and facing treatment program that require change or adaptation that is health needed.

Planning After 1hour of nursing intervention, the client will be able to demonstrate: Willingness to

Nursing Intervention

Rationale

Evaluation After nursing intervention, the client was able to demonstrate: Learned about

healthcare knowledge
Measures BP- 140/90 HR- 51 RR- 22

Ineffective management of therapeutic regimen related to lack of understandin g of the consequence of prescribed treatment plan; difficulty in modifying personal habits; and insufficient financial resources as evidenced by verbalization of noncomplian ce and progression of disease process.

learn about and participate in treatment plan and care.


Willingness to

Reference: Nursing diagnosis: application to clinical practice by Lynda Juall Carpenito-Moyet.

modify personal habits and integrate treatments into lifestyle.


Understanding

Assess patient's: Understanding of disease process Barriers to compliance Life-style Support system Perception of non-compliance Allow patient and s/o to verbalize feelings about situation. Adapt regime to patient's level of comprehension.

- To determine what factors may lead to his noncompliance and find ways to modify it.

- To determine patients attitude toward healthcare management. - To make sure the patient can understand and comply with treatment. - To gain cooperation of the patient.

and participated in treatment plan and care.


Modify personal

habits and integrate treatments into lifestyle.


Understand of

of the implications of not following the prescribed treatment plan.

Involve patient - s/o

in planning compliance and setting goals. Emphasize positive aspects of compliance.

- To ensure goals will be met.

the implications of not following the prescribed treatment plan.

- For the patient to gain knowledge regarding


Abueg, Dorothy Rose S. BSNIV-B1 Group cb1-setA

medication. Instruct patient - s/o about meds: Side effects Dosage


Collaborative:

- To further guide the patient in his therapeutic management.

Consult appropriate health care provider (e.g. social worker, physician) about referrals to community agencies if continued instruction, support, or supervision is needed.

Abueg, Dorothy Rose S. BSNIV-B1 Group cb1-setA

Abueg, Dorothy Rose S. BSNIV-B1 Group cb1-setA

Assessment Objective: CVD Dx: bleeding c standby O2 @ Bedside c good capillary refill in 2-3 seconds c body Malaise Bedridden on CBR w/o BRP c limited ROM dry skin

Nursing Diagnosis Risk for Impaired Skin Integrity r/t prolonged bed rest and altered circulation.

Rationale Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; environmental moisture, especially from incontinence; and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Groups of persons with the highest risk for altered skin integrity are the spinal cord injured, those who are confined to bed or wheelchair for prolonged periods of time, those with edema, and those who have altered sensation that triggers the normal protective weight shifting. Pressure relief and pressure reduction devices for the prevention of skin breakdown include a wide range of surfaces, specialty beds and mattresses, and other devices. Reference: Medical-Surgical Nursing vol. 10th ed. Brunner & Suddarths, pg 1567

Planning After 1-2 hours of Nursing intervention the client will be able to verbalize understanding of individual factors that contribute to possibility of skin integrity impairment and take steps to correct the situation. As evidence by: understanding the situation. patients skin remain intact no redness over bony prominent

Nursing Intervention Place the patient in a comfortable position Take and record vital signs

Rationale To prevent backaches or muscle aches. To note any significant changes that may be brought about by the disease Elderly patients skin is normally less elastic and has less moisture, making for higher risk of skin impairment. Healthy skin varies from individual to individual, but should have good turgor, feel warm and dry to the touch, be free of impairment, and have quick capillary refill (<6 seconds).

Evaluation After 1-2 hours of Nursing intervention the client was able to verbalize and understands of individual factors that contribute to possibility of skin integrity impairment and take steps to correct the situation. As evidence by: understands the situation. patients skin has remain intact no redness seen over bony prominent

Determine age.

Assess general condition of skin.

Abueg, Dorothy Rose S. BSNIV-B1 Group cb1-setA