Nursing Diagnosis Wandering related to premorbid behavior as manifested by outgoing and sociable personality secondary to shadowing a caregivers locomotion.

Subjective Cues: y Kahit ganito na ako gusto ko parin lumabas lagi kesa nasa bahay lang y Minsan din kapag nasa ibang lugar kami, nahihiya

Analysis Meanderin g, aimless, or repetitive locomotion that exposes the individual to harm; frequently incongruen t with boundaries , limits, or obstacles (Nurse s Pocket Guide 11th edition by Marilynn Doenges et al. page 777)

Goal and Objectives After 8 hours of nursing intervention the patient will be able to relax. Objectives: After 1 hour of identifying client s reason for wandering the patient will be able to lessen boredom.

Nursing Intervention Establishing rapport

Rationale

Evaluation

Assess and identify the client s reason for wandering. Open a conversatio n to the patient.

The nurse must listen and observe carefully and use communication techniques that promote better communication in order to understand the needs and feelings of the patient.

http://www.ehow.com/about_5098131_therapeuticcommunication-techniques-nursing.html

What are the identified reason for wandering and boredom of the client?

After 2 hours of modifying environmen t the patient will be able to wander in safe places.

Improve the environmen t for the patient. Limit hazardous materials to prevent injury.

adults relationship to their environment - Loss of balance; cognitive impairment; loss of strength; visual impairment; hearing impairment; and increased sensitivity to cold, drafts, and direct sunlight.

http://www.abcarticledirectory.com/Article/Safehome-environment-for-elderly-citizens/151658

Is the environment for the client a free from injury place and was the place safe?

ako na may taga akay ako.

After 2 hours of assisting the patient in family activities she will be able reduce anxiety and boredom.

Encourage patient to do some activities with the family like chatting with family members, helping in house hold choirs.

y Friends and family can encourage continuation of present physical activities and hobbies. y If walks are appropriate, a stroll on a nice day is a fun and easy way to pass time with a senior. Even pushing a senior in a wheelchair outside can encourage him or her to point to flowers, pets, and such. y If a senior has been inactive, one may still be able to encourage regular exercise. A doctor or physical therapist may provide appropriate exercise and equipment suggestions.

Are there enough activities at home for the patient? Are there enough materials to use?

http://janienne-jennrich.suite101.com/fun-activitiesfor-senior-citizens-a27665

After 3 hours of accompanyi ng the patient she will be able to express her feelings and insights of her boredom.

Encourage the patient to sit down and have a talk and let her express what she feels.

Therapeutic communication begins with the nurse showing respect for the patient and family members and recognizing that communication includes not only verbal responses but also nonverbal expressions, such as tone of voice, body language and facial expression. The nurse must listen and observe carefully and use communication techniques that promote better communication in order to understand the needs and feelings of the patient.

Was therapeutic communicati on effective with the patient?

http://www.ehow.com/about_5098131_therapeuticcommunication-techniques-nursing.html

Activity intolerance related to pain as manifested by weakness.

Insufficient physiologic al or psychologic al energy to endure

After 8 hours of nursing intervention the patient will be able

Cues: y

Kahit ganito na ako, gusto ko parin lumabas lagi pero kapag sumasaki t yung binti ko, ayun d ako makalab as.

or complete required or desired daily activities. (Nurse s Pocket Guide 11th edition by Marilynn Doenges et al. page70)

to tolerate pain activities. Objectives: After 1 hour of identifying precipitating factors of pain, the patient will be able to limit physical activities. After 2 hours of assisting clients in activities the she will be able tolerate pain and enjoy her activities. After 3 of participation in recreational family

Note the age of the patient. Where is the pain located? What aggravates the pain?

Provide assistive devices

Pain is an unpleasant feeling and emotional experience related to injury or damage to the body. This is one of the most common complaints that remains poorly treated in the elderly. An older person may be called an elder. There is no set age for an elder, but it may be defined as when a person retires at the age of 60 or 65 years old. In certain countries, it may be when a person physically cannot do his usual family or work roles anymore. (http://www.drugs.com/cg/pain-management-in-theelderly.html)

What are the factors affecting activity intolerance related to pain?

Minsan din kapag nasa ibang lugar kami, nahihiya ako na may taga akay ako, kaya kadalasa na ay nagpapa

Mobility aids- it is not that age reduces mobility- it just restricts it. And mobility aids enable the aged to around freely without any kind of assistance. (http://www.oldagesolutions.org/AssitivesDevices/AssD ev.aspx) Family recreational activities such as watching movies, family bonding or coffee breaks.

What assistive device is appropriate for the patient?

FACTS ABOUT THE ELDERLY As the human body ages it will inevitably lose some level of the functionality and strength that it once had. A variety of physical impairments will eventually affect all of us. It is important to remember, however,

Are there family recreational activities at home?

iwan ako sa hotel or sa kwarto kapag mamam asyal ang mga anak at apo ko.

activities the patient will be able divert attention and limit pain.

that the challenges of physical aging affect each person in different ways and in varying levels of intensity. Many impairments of aging can hardly be noticed, while others can be debilitating. In order to select appropriate activities for elderly it is important to be aware of the unique physical and sensory challenges they may have. Learning the specific physical and sensory needs of elderly individuals can help you to better determine which activities are most suited for them. (http://www.familyfunshop.com/activitiesfortheelderly .htm)

After 2 hours of demonstrati ng proper use of assistive devices the patient will be able to enjoy routine activities.

provide walker, wheelchair or cane.

The walker or cane should be about the height of your wrists when your arms are at your sides. * When using a walker, your arms should be slightly bent when holding on, but you shouldn't have to bend forward at the waist to reach it. * Periodically check the rubber tips at the bottom of the cane or walker. Be sure to replace them if they are uneven or worn through.

Are this assistive devices available?

Disabled World - Elderly adults who use canes and walkers as walking aids should be assessed and fitted by a physical therapist to avoid fall related injuries: http://www.disabledworld.com/assistivedevices/mobility/walking/fitwalkers-canes.php#ixzz1mXJXGTBT