NCM 103a: FUNDAMENTALS in NURSING PRACTICE SKILLS LECTURE

Name: Block: Group: Score:

Topic: Hygiene and Comfort

Learning Outcomes:
1. Create a nursing care plan for a hypothetical individual focusing on hygiene and comfort.
2. Create a comprehensive and accurate nurse’s notes using the principles and guidelines in charting

Main reference:
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier and Erb’s Fundamentals of nursing. Essex, England: Pearson Education Limited.
Patricia A. Potter ... [et al.] (2013) Fundamentals of nursing, Saint Louis, Missouri : Elsevier, c2013 8th Edition

Activity 1: Nursing Care Plan

INSTRUCTIONS: Read and analyze the situation. Develop NCP for a client with neuromuscular impairment due to stroke focusing on hygiene and comfort. Refer to
the RUBRIC attached for your guidance.

Mr George, a 75 year old male, has been admitted to the medical ward for rehabilitation from having a massive stroke. The client is very slow in speech but is
able to give appropriate answers when asked about how he feels. According to his wife, “Before his stroke condition, he can take care of himself alone”. Mr George now
has generalized body weakness and inability to perform gross and fine motor skills. He has functional level scale of 4 (does not participate in activities). Mild tremors
were also noted on his right hand and arms. “My body is very weak. I cannot bathe myself. I cannot even dress myself and cannot go to the comfort room alone…”
the client stated.

Upon Assessment, the nurse noted the patient is lying on bed with unsatisfying appearance. There is food particles splattered on his clothes and linens are soiled
too. The hair is dry and unfixed with long beard and mustache. The skin is dry and dirty with minimal sweating noted. The client has unpleasant body odor, remaining
teeth are yellowish with visible plaque and tartar accompanied with bad breath. Vital signs taken were Temperature of 37.2 oC, Pulse of 80 bpm, Respirations of 18cpm
and BP of 120/80 mmHg.

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 PROBLEM
EXPLANATION of EVALUATION
(Assessment and OBJECTIVES INTERVENTION RATIONALE EVALUATION
the PROBLEM CRITERIA
Nursing diagnosis)
GOAL -Plan activities with -Energy -The patient will be free MET: The patient
-The patient will the patient prior conservation from body odor showed good hygiene
SUBJECTIVE: have good giving of care to increases activity and comfort after
“My body is very weak. hygiene and prevent fatigue intolerance and -The patient will nursing interventions
I cannot bathe myself. comfort after promotes self-care verbalize the he is PATIALLY MET: The
I cannot even dress nursing comfortable patient showed good
myself and cannot go to interventions -Provide privacy -The need for hygiene but complains
the comfort room when giving care to privacy is important, -The patient will have of being uncomfortable
alone…”, as verbalized the patient some patients are and will show good UNMET: The patient
by the patient SHORT TERM fearful of privacy hygiene throughout the showed signs of lack in
GOAL breaching 3 day shift hygiene and discomfort
OBJECTIVE: -After 3 hours of was shown
-Patient is lying on bed nursing -Assist the patient -Patient and watcher
with unsatisfying interventions, the and watcher to do will be aware of the MET: The patient is free
appearance patient will be bed bath do’s and don’ts in from body with clean,
-Food particles free of body odor bed bath intact skin and with
splattered on his and maintain comfort
clothes and linens are intact, clean skin, PARTIALLY MET: The
soiled too. and linens. -Explain the -The watcher needs patient showed clear,
-The hair is dry and -After 3 hours of procedure and the to be aware that bed intact skin but with body
unfixed with long beard nursing importance to the bathing is important odor. With good comfort
and mustache. interventions, the watcher as it can help in UNMET: The patient still
-Dry and dirty skin with patient will reducing had body odor and
minimal sweating verbalize comfort complications discomfort was shown
noted.
-The client has LONG TERM -Log roll the -As to reduce the MET: The patient and
unpleasant body odor, GOAL patient every 2 cause of watcher showed good
remaining teeth are After 3 days of hours or as ordered complications like signs of having hygiene
yellowish with visible nursing bed sore, etc. and comfort
plaque and tartar interventions, the PARTIALLY MET: The
accompanied with bad patient will show -Instruct the -To avoid possible patient and the watcher
breath. signs of patient and complications showed signs of
improvement in watcher about improving the patient’s
hygiene with the hygiene measures hygiene but with lack of
help of his comfort
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 watcher UNMET: No change
improvements in the
-Change linens -To provide patient’s hygiene and
and clothes of the comfort and comfort
patient promote self-care

REFERENCES:

Activity 2: FDAR Documentation

Instruction: You are to document using FDAR what you have done to Patient George during your 7-3 shift duty. Refer to the RUBRIC attached for your guidance.

NURSES’ NOTES
Date and
NOTES
Time

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