NURSING PROBLEM EXPLANATION GOAL INTERVENTION RATIONALE EVALUATION

Self care deficit Trauma  Identify individual Provide privacy during The need for privacu is The resources were
Subjective: areas of dressing. fundamental for most identified which are
“mabainak ag bawas” as weakness/needs. patients. They may take useful in optimizing the
verbalized by the  Verbalize longer to dress and may be autonomy and
patient. knowledge of fearful of breaches in independence of the
health practices. orivacy. patient in his hygiene,
Objective: Fracture  Demonstrate dressing or grooming,
 Inability to techniques/lifestyle Give frequent Assistance can reduce and in toileting.
perform toileting changes to meet encouragement and aid energy expenditure and
tasks self-care needs. with dressing as needed. frustration. However, care
independently  Perform self-care needs to be taken so the
 Inability to bathe Limited range of motion activities within care provider does not rush
independently level of own through tasks, negating the
 Inability to ability. patient’s attempts.
ambulate LTO:
independently Resources will be Establish regular A plan that balances
 Uses bed pan Impaired physical identified which are useful activities so tha patient is periods of activity with
mobility in optimizing the rested before activity, periods of rest can help the
Nursing Diagnosis: autonomy and patient complete the
Self care deficit related independence of the desired activity without
to impaired mobility patient undue fatigue and
. frustration.
Self care deficit
Assess and note prior and The efficacy of the bowel
present patterns of or bladder program will be
toileting; introduce a improved if the natural and
toileting routine that personal patterns of the
factors these habits into patient are taken into
the program. consideration.

Assess patient’s ability to Patient may have

verbalize necessitate to
void and/or capacity to
use urinal, bedpan. Bring
patient to the bathroom at
regular or intermittent
intervals for voiding if
suitable.
neurogenic bladder, is
lacking concentration, or
be able to verbalize needs
in acute recovery phase,
but often is able to recover
independent control of this
function as recovery
develops.

Provide privacy while Lack of privacy may

patient is toileting. reduce the patient’s ability
to empty bowel and
 bladder.

Give bedpan or put This

patient on toilet every 1 eradicates incontinence.
to 1½ hours throughout Time intervals can be
day and three times prolonged as the patient
throughout night. starts to verbalize the need
to toilet on demand.

Educate family and This displays caring and

significant others to concern but does not
promote autonomy and to hinder with patient’s
intervene if the patient efforts to attain autonomy.
becomes tired, not
capable of carrying out
task, or become
extremely aggravated.