Some Common Problems And Corresponding Strengths On The Wards……..
Applies To Both Medical & Surgical Wards
Prepared By AKONVARE
Patient’s Problems
1. Patient has pain in his/her lower limbs
2. Patient has difficulty swallowing
3. Patient is prone to urethral infection due to catheter
insitu
4. Patient cannot bath by him/herself
5. Patient cannot bath without assistance in bed or
bathroom
6. Patient has high body temperature (38.2°C)
7. Patient has wound on his/her thigh
8. Patient is prone to pressure ulcers/sores
9. Patient has soiled/dirty linen
10. Patient is anxious about (unknown prognosis of illness
or change in environment or impending surgery)
11. Patient has inadequate information on (medications, or
illness or surgery)
12. Patient has difficulty breathing
13. Patient has loss appetite for food
Patient’s Strengths
1. Patient can verbalize the intensity and location of pain
2. Patient has Naso-gastric tube in-situ
3. Patient is willing for urethral catheter to be cared for
4. Patient can cooperate for bed bath to be done
5. Patient can be bathed with an assistance
6. Patient is willing for tepid sponge to be done
7. Patient can assume comfortable position for wound dressing to be done
8. Patient can adapt positional changes
9. Patient is willing for bed linen to be changed
10. Patient can verbalize his/her fears about (unknown prognosis of illness,
or change in environment, or impending surgery)
11. Patient is ready to be educated on (medications, or illness or surgery)
12. Patient can tolerate oxygen therapy, or Patient can be prop up in bed, or
Patient can be put into a cardiac bed.
13. Patient could eat in bit and at regular intervals
 Corresponding Care Plan
Nursing Diagnosis
Acute pain related to
inflammatory process in the
lower limbs
Impaired swallowing related to
illness (e.g stroke)
Risk for infection related to
urethral catheter in- situ
Bathing self-care deficit
related to general body
weakness
Obj & Outcome C
Patient will be relieved from pain with 30 mins as
evidenced by patient verbalizing pain has
subsided
Patient will be able to swallow through the NG
tube within 30mins as evidenced by nurse
observing that patient is fed trough the NG tube
Patient catheter will be cleaned to prevent
infection within 30mins as evidenced by Patient
verbalizing her urethral catheter has been care for
Patient will be bathed with 40mins as evidenced
by patient verbalizing he/she is refreshed and
clean in bed
Nursing Orders
Reassure and asses pain level
Apply warm compress to the site
Check vital signs
Served prescribed analgesic
Reassure and elevated head end of bed
Assess proper positioning of NG tube
Feed patient through NG tube
Record fluid diet on the intake and output chart
Reassure and observe urethral orifice for signs of
infection
Care for patient’s urethral catheter aseptically
Record urine output
Administer prescribed prophylactic antibiotic
Reassure and provide privacy
Bath patient in bed
Treat pressure areas
Groom patient
Bathing self-care deficit
related to (pain or fracture in
the right or left upper arm)
Hyperthermia (38.20C) related
to disturbance in the
hypothalamus
Risk for infection related to
break in the continuity of the
skin (wound at the thigh)
Risk for pressure ulcers related
to prolong stay in bed
Impaired comfort related to
soiled/dirty linen
Anxiety related to (unknown
Patient will be assisted to bathed with 30mins as
evidenced by patient verbalizing he has looks
clean
Patient’s high body temperature will be subsided
to normal within 30mins as evidence by Patient
verbalizing he/she is not warm to touch and
Nurse observing patient’s temperature is within
normal range (36.2 – 37.2)
Patient’s wound will be dressed to prevent
infection within 40mins as evidenced by Nurse
observing patient wound looks clean and healing
Patient’s pressure areas will be treated to prevent
ulcers/sores with 30mins as evidenced by patient
verbalizing that his/her pressure points have been
treated.
Patient will be comfortable within 30mins as
evidenced by patient verbalizing his/her linen
looks neat and nurse observing patient relaxed in
bed
Patient will be relieved from anxiety within
Reassure and provide privacy
Assist patient to bath
Treat pressure areas
Assist patient to Groom
Reassure and provide good ventilation
Check patient’s vital signs such as temperature
Tepid sponge patient
Serve prescribed antipyretic if available
Reassure and assess wound for signs of infection
Dress wound aseptically
Serve patient with diet high in protein and vitamin
Administer prescribed antibiotic
Reassure and provide privacy
Clean and treat patient’s pressure areas
Groom patient
Turn patient every 2 hours
Reassure patient for competency of care
Place patient is a comfortable position to help change
soiled linen
Protect bed clothes before performing procedures in
bed
Serve bedpan and urinal on demand
Reassure patient for competency of care
prognosis of illness or change
in environment or impending
surgery)
Deficient knowledge related to
inadequate information on
(medications, or illness or
surgery)
Ineffective breathing pattern
related to decreased lungs
expansion or poor position in
bed
Risk for imbalance nutrition;
less than body requirement
related to loss of appetite
OR
Anorexia related to (severe
pain, nausea and vomiting)
45mins as evidenced by Patient verbalizing,
he/she is ready to go for the surgery and Nurse
observing patient is fully participating in his/her
care.
.
Patient will gain adequate knowledge on
(medications, or illness or surgery) within 40mins
as evidenced by Patient answering about 70% of
questions asked on what was thought correctly
Patient’s breathing pattern will be improved with
45mins as evidenced by patient showing no signs
od difficulty breathing such as gasping for air.
Patient will be fed to improve nutritional status
within 30mins as evidenced by patient eating
about 2/3 of meal served and nurse observing no
signs of malnutrition
OR
Patient will regain his/her appetite for food with
35mins as evidenced by patient eating about 2/3
of meal served
Explain all procedures to patient and Allow patient to
ask questions.
Introduce patient to other patients who have undergone
similar state and are recovering well.
Provide diversional therapy for patient
Assess patient level of knowledge on (medications, or
illness or surgery)
Educate patient on (medications, or illness or surgery).
Encourage patient to ask questions on what he/she has
learnt.
Advice patient on the need to continue treatment
Reassure patient for competency of care
Make cardiac bed for patient
Check patient vital signs especially respiration
Administer prescribed humidified oxygen
Reassure patient for competency of care
Remove all nauseating items from bedside
Perform oral hygiene for patient to boost appetite
Feed patient with a well balanced diet