Cues Nursing Diagnosis Planning Implementation Rationale Evaluation

Independent:
SUBJECTIVE: Self-bathing/ GOAL: Evaluate
“ Ang hirap ng hygiene deficit 1) Determine existing > To identify responses to
ganito, nakahiga related to musculo- After 1 day of conditions causative/ interventions,
na lang lagi, kahit skeletal impairment nursing affecting ability of contributing teachings and
paligo inaasa sa as evidenced by intervention, the individual to care factors actions
iba,” as verbalized inability to wash patient will for own needs, i.e. performed.
by the patient body or body parts, perform self-care spinal cord injury.
obtain or get to activities within 2) Determine *The client was
OBJECTIVE: water source, get in level of own individual > To assess able to perform
> patient has been and out of ability strengths of client degree of self-care
bedridden ever bathroom. 3) Note whether disability activities within
since she was EXPECTED deficient is >To assess degreelevel of own
hospitalized OUTCOME: temporary or of disability ability.
because of spinal The patient will: permanent, should Goal was met
cord injury 1) Identify decrease or
individual increase in time
areas of 4) Promote client/ SO
weakness/ participation in >enhances
needs problem commitment to
2) Demonstrate identification and plan, optimizing
techniques/ decision making. outcomes
lifestyle 5) Develop plan of
changes to care appropriate to > to assist in
meet self- individual correcting/ dealing
care needs situation, with situation
3) Identify scheduling
personal activities to
resources conform to clients
that can normal schedule. > To enhance
provide 6) Assist with rehab capabiities
assistance program > To enhance
7) Allow sufficient capabilities
time for client to
accomplish tasks
to fullest extent of
ability >To encourage
8) Assist with client and build on
necessary successes.
adaptation to
accomplish ADL’s.
Begin with familiar,
easily
accomplished
tasks. >Assist patient to
9) Review/modify adhere to plan of
program care to fullest
periodically to extent
accommodate
changes in abilities >To provide
continuity of care
Dependent:
10)Administer
medication > To provide
regimen continuity of care
Collaborative:
11)Consult with
dietitian/nutritional
support team