NURSING DIAGNOSIS 1.

) Risk for Activity Intolerance

INTERVENTIONS Independent Interventions:

EVALUATION

2.) Anxiety related to perceived threat to physical integrity as manifested by verbalization of, mahadlok ko mubalik ni akong hernia cues: client is scared as verbalized by, mahadlok ko mubalik ni akong hernia Scientific Basis: A common reaction to stress is anxiety, a state of mental uneasiness, apprehension, dread or foreboding or a feeling of helplessness related to an impending or anticipated threat to self or significant relationships. Anxiety is considered to be a normal reaction to stress. It may help a person to deal with a difficult situation by prompting one to cope with it. Source: Fundamentals of Nursing. Kozier and Erb. Eighth Edition. Volume two. Page 1064.

Independent Interventions: 1.) Assess client's level of anxiety. R: To be able to determine the level of anxiety, whether mild, moderate or severe so appropriate care and management can be given. 2.) Maintain a calm and tolerant manner while interacting with the client. R: Another person's anxiety, especially a nurses' attitude may be easily perceived by the client and could worsen anxiety. 3.) Establish a working relationship with client through continuity of care. R: An ongoing relationship establishes a basis for communicating anxious feelings. 4.) Assist in developing anxietyreducing skills like relaxation, deep breathing, and positive visualization.

Desired Outcome: Within 2 hours of student nurse client interaction, the client will be able to demonstrate positive coping methods and be able to have knowledge on his case on inguinal hernia. Actual Outcome: After 2 hours of student nurse client interaction, the client was able to learn the different coping and anxiety reducing methods and was able to know what can trigger the hernia to reoccur as verbalized by, ahw lage, mao bitaw di ayo ko mag alsa-alsa ug bug-at kay basin unya mubalik ni.

R: Utilizing anxiety-reduction strategies enhances client's sense of personal mastery and confidence and help ease anxious feelings. 5.) Give health teachings on inguinal hernia and what could cause its reoccurrence. R: For the client to be aware of what could cause his hernia to reoccur and also to prevent it from reoccurring. 6.) Maintain a calm and tolerant environment R: The client's feeling of stability increases in a calm and nonthreatening atmosphere Independent Interventions:

3.) Disturbed Sensory Perception related to problem with vision as manifested by squinting of the eyes when reading the bible as verbalized, dili ko makaklaro 1.) Encouraged to eat nutritious inig basa naku sa bible kay magsikit ang mga letra. food that are rich in Vit. A such as squash and tomatoes. Cue: R: it helps for proper vision Squinting of eyes when reading the bible 2.) Advised to rest eyes for about 15 mins. Scientific Basis: R: helps to promote People who have myopia are said to be nearsighted. proper circulation of blood in the They have deeper eyeballs. They have deeper eyeballs; eyes. the distal visual image focuses on front of the retina. Most of these people experience blurred distant vision. 3.) Instructed to avoid reading at dark places Source:

Desired Outcome: After 2 hours of nursing interventions the client will be able to follow the suggestions or the advice given by the student nurses and use resources effectively and appropriately. Actual Outcome: After 2 hrs of nursing interventions the client was able to understand and ask questions for clarification.

Medical-Surgical Nursing (10th edition) pp. 1752 Author: Suzanne C. Smeltzer

R: it worsens the underlying condition 4.) Instructed to sleep with the right period of time. R: to promote relaxation of the eyes and maximizes energy of the body. 5.) Advised to have a check-up in the health center. R: to rule out the underlying cause. 6.) Instructed to wear eyeglasses if needed R: to view things clearly 7.) Noted factors that worsen the condition. R: to identify management for that condition. 8.) Encouraged to drink oral fluids R: helps to clear vision Independent Interventions: 1.) Assess clients motor skills ease and capability of movement. R: to determine clients ability 2.) Determined usual exercise and physical limitations R: to know the underlying condition

4.) Sedentary Lifestyle related to lack of time to perform exercise as manifested by slight weakness and verbalization of wala na koy oras para magexercise. Cue: Verbalization of, wala na koy oras para magexercise.

Desired Outcome: After 2 hours of nursing intervention the client will be able to verbalize importance of exercise to general well being. Actual Outcome: After 2 hours of nursing intervention the client was able to state the benefits of doing

Scientific Basis:

Evidence exercise shows that exercise can prevent and reverse many of the chronic diseases experienced by aging adults. Regular exercise is important for us and sedentary lifestyle increases the chances of becoming overweight as well as developing chronic diseases including anxiety. Source: Fundamentals of Nursing (8th edition) pp. 1170 Author: Kozier and Erbs

3.) Discussed motivation for change R: to gained energy and relieved stress 4.) Instructed to perform exercise at least twice a week R: to make body strong 5.) instructed in safety measures as individually indicated R: to promote safety

exercise.

5.) Ineffective Health Maintenance related to insufficient resources as manifested by financial problem as verbalized, dili gyud madali ug adto sa ospital kung naay sakit kay wala mi igo nga kwarta. Cue: Verbalization of, dili gyud madali ug adto sa ospital kung naay sakit kay wala mi igo nga kwarta.

Independent Intervention: 1.) Advised to have a check-up in the health center. R: to determine the underlying cause of the condition 2.) Encouraged to eat nutritious foods R: helps to increase resistance against disease 3.) Instructed to avoid doing things that would lead to disease such as drinking too much alcohol R: to prevent further problem to their situation 4.) Provided anticipatory guidance R: to maintain and manage health practices during periods of wellness. 5.) Advised to ask help to their congressman or other government who give services to those in need. R: to get the needs they want Independent Interventions: 1.) Assess past pattern of sleep in normal environment R: Sleep patterns are unique to

Desired Outcome: After 2 hours of nursing intervention the client will be able to identify necessary health maintenance activities and verbalize understanding of factors contributing to current situation.

Scientific Basis: The nurse may encounter patients who are experiencing an alteration in their ability to maintain health either in the hospital or in the community, but the increased presence of the nurse in the community and home health settings improves the ability to assess patients in their own environment. Altered health maintenance reflects a change in an individuals ability to perform the functions necessary to maintain health or wellness. That individual may already manifest symptoms of existing or impending physical ailment or display behaviors that are strongly or certainly linked to disease. Source: http://www1.us.elsevierhealth. com/MERLIN/Gulanick/Constructor/index.cfm?plan=2 7 6.) Disturbed Sleeping Pattern related to anxiety and normal changes associated with aging as manifested by expression of anxiety and client wakes up in the middle of the night and finds it hard to fall back to sleep again.

Actual Outcome: After 2 hours of nursing intervention the client was able to understand ways on how to prevent disease and where could ask help if these problem arises.

Desired Outcome: After 1 week the client will be able to achieve optimal amounts of sleep as evidenced by rested appearance, and verbalization of feeling rested,

Cues: Anxiety as verbalized, mahadlok ko mubalik ni akong hernia Client wakes up in the middle of the night and finds it hard to fall back to sleep again as verbalized, mag mata-mata ko sa kadlawn. Mao na siguro ni resulta sa magka,tiguwang ta Scientific Basis: Sleep is a basic human need; it is a universal, biological process common to all people. Sleep is characterized by minimal physical activity, variable levels of consciousness, changes in the body's physiologic process, and decreased responsiveness to external stimuli. Some environmental stimuli will usually awaken a sleeper and disturb ones usual sleep pattern. Source: Fundamentals of Nursing. Kozier and Erb. Eighth Edition. Volume two. Page 1164.

each individual. 2.) Assess client's perception of cause of sleep difficulty and possible relief measures R: To facilitate treatment. 3.) Maintain an environment conducive to sleep and rest R: To promote relaxation 4.) Assist client in observing previous bedtime rituals R: To promote relaxation 5.) Encourage a member of the family to perform back rubs, or encourage client to sleep in comfortable positions, and relaxation techniques. R: To promote rest and relaxation. 6.) Provide soporifics like milk, and avoid stimulants like caffeine and cola beverages before several hours before sleeping R: To facilitate in rest and relaxation 7.) Discourage daytime or afternoon naps unless deemed necessary or part of usual pattern. R: Naps can disrupt normal sleep

and improvement in sleeping pattern. Actual Outcome: After 1 week the client was able to sleep well as verbalized, maayo naman akong tulog dae. Dili na kaayo ko mag mata-mata di pareha sauna.

patterns. 8.) Limit fluids during night before sleep R: To avoid or reduce the need to void during night and disrupt sleep Independent Interventions: 1.) Assess for presence r existence of risk factors R: To be able to determine risk factors and give prompt treatment and management 2.) Monitor for signs of infection R: To detect signs and symptoms early and be able to give prompt care and treatment 3.) Assess nutritional status including weight, and history of weight loss R: Client's with poor nutritional status may be immunocompromised and therefore be more susceptible to infections 4.) Assess immunization status R: Those who have not completed immunizations have no sufficient acquired immunocompetence 5.) Wash hands before and after

7.) Risk for Infection related to failure to avoid pathogens as manifested by crowded environment and presence of cockroaches and rodents and insects. Cues: Presence of cockroaches, rats and flies and mosquitoes. Community is crowded and polluted Scientific Basis: Microorganisms exist everywhere: in water, soil, and on body surfaces such as intact skin, intestinal tract, and other areas open to the outside. Infectious diseases are a major cause of death worldwide. The control of the spread of microorganisms and the protection of the people from communicable diseases and infections are carried out on the international, national, state, community, and individual level. Source: Fundamentals of Nursing. Kozier and Erb. Eighth Edition. Volume one. Page669-670.

Desired Outcome: Within 2 hours of student nurseclient interaction the client will be able to maintain a clean and safe environment and remain free from infection and recognize infection early to allow prompt treatment. Actual Outcome: After 2 hours of student nurse-client interaction the client was able to client was responsive to health teachings, by nodding and asking clarifications and after one week, client maintained a clean environment and showed no signs of infections.

contact with the client and taught client on proper hand washing and how frequent R: To reduce risk of transmitting pathogens from one part of the body to the other and from one person to the other. 6.) Teach client the importance of avoiding contact with those who have infections, colds, and diseases R: To prevent transmission and avoid possible contamination and other complications 7.) Teach client the signs and symptoms of infection and to report this to a doctor immediately R: To prevent complications and other illness Independent Interventions: 1.) Explained the words in simple terms according to the level of understanding. R: to facilitate learning 2.) Provided information relevant only to the situation. R: to prevent overload 3.) Provided positive reinforcement R: to encourage continuation of

8.) Deficient Knowledge related to lack of information as verbalized, mahadlok gyud ko aning ako ang hernia kay basin mous-us napud. Cue: Verbalization of mahadlok gyud ko aning ako ang hernia kay basin mous-us napud.

Desired Outcome: After 2 hours of nursing intervention the client will be able to participate in the learning process, show increased interest for own learning by beginning to look for information and ask questions. Actual Outcome: After 2 hours of nursing intervention the client was able to understand and raise questions for his clarification.

Scientific Basis: Many factors influence patient education, including age, cognitive level, developmental stage, physical limitations. The nurse must decide with the

learner what to teach, when to teach, and how to teach the mutually agreed-on content. Sources: http://www1.us.elsevierhealth. com/MERLIN/Gulanick/Constructor/index.cfm?plan=2

efforts 4.) Determined motivating factors for the client R: to promote health or to prevent disease 5.) Determined clients method of accessing information R: to facilitate learning 6.) Instructed to have a check-up in the health center or hospital R: to determine if there is still a chance that hernia would occur again 7.) Provided active role for client in learning process. R: to promote self of control over situation 8.) Explained accurately to the client R: to avoid confusion Independent Interventions:

9.) Interrupted Family Process

10.) Impaired Home Maintenance/ Management related to lack of knowledge as manifested by unsafe home environment and lack of basic hygiene

Independent Interventions: 1.) Perform home assessment

Desired Outcome: Within 2 hours of student nurse client interaction the client will be

measurements like presence of vermin in home, and accumulation of wastes as revealed by home visits. Cues: Presence of cockroaches, rats, and flies and mosquitoes Polluted outside surroundings Scientific Basis: Health or safety may be threatened when one's home is not maintained properly and there may be a threat to relationships or to the physical well-being of the people living in the home. An inability to perform the activities necessary to maintain a home may be the result of the development of chronic mental or physical disabilities, or acute conditions or circumstances that severely affect the vulnerable members of the household. The patients home must be safe and suited to the recovery needs of the individual.

R: To evaluate for accessibility and physical barriers. 2.) Assess client's knowledge on the importance of personal and environmental hygiene and safety R: It could be possible that knowledge deficit could be responsible for poor home maintenance because they do not know and see its importance and significance 3.) Assess patient's physical ability to perform home maintenance. R: Client cannot lift heavy objects or perform any strenuous activities because of his condition

able to start and maintain a clean environment. Actual Outcome: After 2 hours of student nurse-client interaction, client was responsive to health teachings. And after 1 week client's home is clean and well organized, no signs of rats or cockroaches noted. Flies and mosquitoes still noted.

4.) Encourage to evenly distribute chores and workload Source: http://www1.us.elsevierhealth.com/MERLING/Gulanick R: To help in home maintenance and to prevent fatigue during the /Constructor/index.cf?plan=28 performance of physical activities 11.) Readiness for Enhanced Family Process Independent Interventions:

12.) Readiness for Enhanced Spiritual Well-being

Independent Interventions: