Chapter VII

NCP
Name: Patient M.C.E. Date: October 28, 2019

Age/Sex: 43 years old/Female Area: Lorma 3C

Problem: Deficient Knowledge

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Deficient knowledge After 1-2 hours of Independent: Goal Met.

“Dik ammo no anya regarding cause of nursing interventions, -Monitor vital signs -Use as a baseline data to After 1-2 hours of

talaga iti gapo na datoy condition and the patient will be able determine underlying nursing intervention,

sakit ko.” As verbalized treatment as to: condition patient was able to

by the patient. evidenced by lack of -Participate in the participate in the

Objective: cognitive information learning process learning process

HR: 68 or psychomotor -Verbalize -Establish rapport -To gain patient and and verbalized

RR: 21 ability needed for understanding of the relative’s trust and have a “Ammok tattan no

T: 36.9℃ health restoration, disease process good student nurse-patient anya talaga iti gapo

O2Sat: 98% preservation or relationship na datoy kondisyon

health promotion. ko.”

-Evaluate desire/readiness to -Determines amount or

learn level of information needed

-Provide an atmosphere of -Important when providing

respect, openness, trust and education to patients with

collaboration different values and beliefs

about health.

-Provide health teachings -Helps the patient gain

about the health problem, its knowledge about the

causes, risks, prevention and diseases process by

management providing an organized flow

of teaching
Name: Patient M.C.E. Date: October 28, 2019

Age/Sex: 43 years old/Female Area: Lorma 3C

Problem: Dizziness

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for fall related to After 1-2 hours of Independent: Goal partially met.

“Maul-ulaw ak ma’am.” dizziness nursing interventions, -Monitor vital signs -Use as a baseline data to

As verbalized by the the patient will be able determine underlying After 1-2 hours of

patient. to: condition nursing interventions,

Objective: -Not sustain or prevent patient still has

HR: 65 fall. complaints of dizziness

RR: 20 -Relate the intent to -Establish rapport -To gain patient and but is able to not sustain

T: 36.6℃ use safety measures relative’s trust and have a fall as well as able to

O2Sat: 97% to prevent falls. good student nurse-patient relate safety measures

-Demonstrate selective relationship and demonstrate

prevention measures. selective prevention

- measures.
-Use side rails on beds, as -According to research, a

needed disoriented or confused

patient is less likely to fall

when one of the four rails is

left down.

-Encourage the patient to don -Nonskid footwear provides

shoes or slippers with nonskid sure footing for the patient

soles when walking. with diminished foot and toe

lift when walking.

-Teach client how to safely -This will help relieve

ambulate, including using anxiety and eventually

safety measures such as decreases the risk of falls

handrails in bathroom. during ambulation.

Name: Patient M.C.E. Date: October 28, 2019

Age/Sex: 43 years old/Female Area: Lorma 3C

Problem: Fatigue

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Fatigue related to After 1-2 hours of Independent: Goal Met.

“Agkakapsot ak ma’am.” decreased nursing interventions, -Monitor vital signs -Use as a baseline data to After 1-2 hours of

As verbalized by the hemoglobin and the patient will be able determine underlying nursing intervention,

patient. diminished oxygen- to: condition patient was able to

Objective: carrying capacity of -Verbalize use of participate in the

HR: 70 the blood. energy conservation learning process

RR: 20 principles. -Establish rapport -To gain patient and and verbalized

T: 36.8℃ -Verbalize reduction of relative’s trust and have a “Haan ak unay

O2Sat: 97% fatigue, as evidenced good student nurse-patient agkakapsoten

by reports of increased relationship ma’am.”

energy and ability to

perform desired - Evaluate the patient’s - Using an appropriate

activities. description of fatigue: severity, quantitative scoring scale, 1

changes in severity over time, to 10 for example, can aid

aggregating factors or the patient formulate the

alleviating factors. amount of fatigue

experienced.

- Evaluate the patient’s outlook - These will promote active

for fatigue relief, eagerness to participation in planning,

participate in strategies to implementing, and

reduce fatigue, and level of evaluating therapeutic

family and social support. management to alleviate

fatigue. Social support will

be essential to assist the

patient put into practice

changes to decrease

fatigue.

- Restrict environmental - Vivid lighting, noise,

stimuli, especially during visitors, numerous

planned times for rest and distractions, and litter in the

sleep. patient’s physical

surroundings can limit

relaxation, disturb rest or

sleep, and contribute to

fatigue.

- Identify energy conservation - Weakness can make

methods such as sitting and ADLs almost not possible

dividing ADLs into convenient for patient to finish. Being

segments. Assist with with the patient prevents

movement or self-care the patient from getting

demands as appropriate. harm during activities.

- Educate the patient and - Organization and

family about task organization management of time can

methods and time organization assist the patient save

methods. energy and avoid fatigue.