N Tetanus 154o6y
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NURSING LONGTERM SHORT CUES DIAGNOSIS GOAL TERM GOAL S”Konti lang Disturbed After 5 days After 4 hrs. ang tulog sleep pattern of nursing Of nursing of niya mga 2 r/t interventions intervention hours at biochemical the patient the patient paputolagents such will be able to relatives will putol.” as medicines maintain and be able to verbalized by improve sleep verbalize husband of pattern. understandin the patient g of necessary O: intervention (+)Sunken to improve eye balls sleep pattern. (+) Weakness (+) Yawning (+) Fatigue appearance
NURSING INTERVENTION >Monitored v/s
RATIONALE
EVALUATION
To note changes and a LONGTERM GOAL: serves as baseline data After 5 days of nursing, interventions >Assessed patient It may contribute in the patient able to schedule of sleep. disturbing sleep maintained and; pattern at night. improved sleep pattern as evidenced by 4-6 hours of sleep >Instructed patient To decrease tension, at night relaxation techniques. prepare for sleep. SHORTTERM >Instructed patient to To reduce need for GOAL: limit fluid intake at nighttime elimination. night. After 4 hours of nursing intervention the patient relatives >Instructed patient To reduce stimulation was able to verbalized family to provide that the client may understanding of quite environment. relax and fall asleep. necessary intervention to improve sleep pattern.
CUES
S:”di nga siya pwedeng tumayo sabi ni Dok” verbalized by the husband of the pt. O: (+) Leg muscle weakness >Inability to performed ADL >Reluctance to attempt movement > Limited range of motion >Doctors order of CBR. (+) Tracheostom y
NURSING DIAGNOSI S Impaired physical mobility r/t prescribed movement restriction. (Functional level IV; Dependent, does not participate in activity.)
LONGTER M GOAL
SHORTTERM NURSING GOAL INTERVENTION
RATIONALE
EVALUATION
After 5 days of nursing intervention the pt will be able to maintain position of function and skin integrity as evidence by absence of contractures, footdrop, decubitus and etc..
After 8 hrs of nursing intervention the patient relatives will be able to verbalize understanding of situation and risk factors and individual treatment and regimen and safety measures.
>Monitored v/s
To note changes and possible signs of complication and serves as baseline data
>Assessed patient signs of fatigue, pain and difficulty of breathing
It may result in activity intolerance
After 5 days of nursing intervention the pt will be able to maintain position of function and skin integrity as evidence by absence of contractures, footdrop, decubitus and etc..
>Assisted client in repositioning every 2 hours or as needed
Optimizes circulation and to all tissue and relieves pressure.
> Provided patient daily scheduled of exercise
To enhance more his body mechanics
> Instruct patient/family regarding needs to make home environment safe
A safe environment is a prerequisite to improved mobility.
> Provide safety For safety of the pt. measures as indicated in pt situation.
SHORTTERM GOAL: After 8 hrs of nursing intervention the patient relatives will be able to verbalize understanding of situation and risk factors and individual treatment and regimen and safety measures.
CUES S:”Di pa magaling ung suagat niya gawa ng pag papaopera niya sa lalamunan” as verbalized by the husband of the pt. O: (+) Floppy skin 76 yrs old (+) Tracheostomy
NURSING LONGTERM SHORTTERM NURSING DIAGNOSIS GOAL GOAL INTERVENTION
RATIONALE
EVALUATION
Impaired skin integrity r/t mechanical factors secondary to surgery.
>Monitored vital signs
To note changes and possible signs of complication and serves as a baseline data
>Monitored fluid intake and output.
To note fluid retention
>Assessed patient skin color, texture and turgor.
To assess extent of involvement
LONGTERM GOAL: After 5 days of nursing intervention the pt relatives was able to participate in prevention measures and treatment program.
>Instructed pt. relatives to keep area clean and dry
To prevent further complication
>Instructed patient to apply lotion
To maintain moisturize skin
>Instructed patients Family to provide optimum nutrition including vitamins and increase protein intake
To provide a positive nitrogen balance to aid in skin healing
>Encouraged patient to take multivitamins
To increase immunity
After 5 days of nursing intervention the pt relatives will be able to participate in prevention measures and treatment program.
After 8 hours of nursing intervention the patient relatives will be able to verbalize understanding of how to promote early healing of wound.
SHORTTERM GOAL: After 8 hours of nursing intervention the patient relatives was able to verbalized understanding of how to promote early healing of wound.
CUES O: 76 yrs old (+) Tracheostomy
NURSING DIAGNOSIS
LONGTERM GOAL
SHORTTERM GOAL
NURSING INTERVENTION
RATIONALE
EVALUATION
Risk for infection related to inadequate primary defense
After 5 days of nursing intervention the patient will be able to maintain good hygiene
After 4 hours of nursing intervention the patient relatives will be able to identify intervention that will prevent/reduce risk of infection of the patient
>Monitored vital signs
To note changes and possible signs of complication and serve as baseline data
LONGTERM GOAL: After 5 days of nursing intervention the patient was able to maintained good hygiene
>Assessed patient nutritional status including history of weight loss
Patients with poor nutritional status may be anergic, or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection.
>Instructed patient of daily bathing and hand washing
To reduce risk
>Encourage intake of protein- and calorierich foods.
This maintains optimal nutritional status.
>Encouraged patient to take vitamins such as vitamin C
To increase and strengthen immunity
SHORTTERM GOAL: After 4 hours of nursing intervention the patient relatives was able to identified intervention that will prevent/reduce risk of infection of the pt.
CUES
S; “ Inuubo pa rin siya.” Verbalized by the husband of the pt.
O; (+) productive cough (+)Wide eyed (+)Restlessness
NURSING DIAGNOSIS
LONGTERM GOAL
SHORTTERM GOAL
NURSING INTERVENTION
RATIONALE
EVALUATION
Ineffective airway clearance r/t excessive mucus secretions
In 5 days of nursing intervention the patient will be able to expectorate/ clear secretions readily
After rendering immediate nursing intervention the pt will be able to maintain airway patency
>Suction endotracheal
To clear airway when secretion are blocking airway.
LONGTERM GOAL: After rendering immediate nursing intervention the pt was able to maintain airway patency
>Elevated head of the bed, change position every 2 hours.
>Monitored vital sign
To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of ventilation to different lung segment. To note the any progress Lessen fatigue
>Provided opportunities for rest > istered O2 as needed
To provide airway
SHORTTERM GOAL: In 5 days of nursing intervention the patient was able to expectorate but not cleared the secretions readily
NURSING INTERVENTION >Monitored v/s
RATIONALE
EVALUATION
To note changes and a LONGTERM GOAL: serves as baseline data After 5 days of nursing, interventions >Assessed patient It may contribute in the patient able to schedule of sleep. disturbing sleep maintained and; pattern at night. improved sleep pattern as evidenced by 4-6 hours of sleep >Instructed patient To decrease tension, at night relaxation techniques. prepare for sleep. SHORTTERM >Instructed patient to To reduce need for GOAL: limit fluid intake at nighttime elimination. night. After 4 hours of nursing intervention the patient relatives >Instructed patient To reduce stimulation was able to verbalized family to provide that the client may understanding of quite environment. relax and fall asleep. necessary intervention to improve sleep pattern.
CUES
S:”di nga siya pwedeng tumayo sabi ni Dok” verbalized by the husband of the pt. O: (+) Leg muscle weakness >Inability to performed ADL >Reluctance to attempt movement > Limited range of motion >Doctors order of CBR. (+) Tracheostom y
NURSING DIAGNOSI S Impaired physical mobility r/t prescribed movement restriction. (Functional level IV; Dependent, does not participate in activity.)
LONGTER M GOAL
SHORTTERM NURSING GOAL INTERVENTION
RATIONALE
EVALUATION
After 5 days of nursing intervention the pt will be able to maintain position of function and skin integrity as evidence by absence of contractures, footdrop, decubitus and etc..
After 8 hrs of nursing intervention the patient relatives will be able to verbalize understanding of situation and risk factors and individual treatment and regimen and safety measures.
>Monitored v/s
To note changes and possible signs of complication and serves as baseline data
>Assessed patient signs of fatigue, pain and difficulty of breathing
It may result in activity intolerance
After 5 days of nursing intervention the pt will be able to maintain position of function and skin integrity as evidence by absence of contractures, footdrop, decubitus and etc..
>Assisted client in repositioning every 2 hours or as needed
Optimizes circulation and to all tissue and relieves pressure.
> Provided patient daily scheduled of exercise
To enhance more his body mechanics
> Instruct patient/family regarding needs to make home environment safe
A safe environment is a prerequisite to improved mobility.
> Provide safety For safety of the pt. measures as indicated in pt situation.
SHORTTERM GOAL: After 8 hrs of nursing intervention the patient relatives will be able to verbalize understanding of situation and risk factors and individual treatment and regimen and safety measures.
CUES S:”Di pa magaling ung suagat niya gawa ng pag papaopera niya sa lalamunan” as verbalized by the husband of the pt. O: (+) Floppy skin 76 yrs old (+) Tracheostomy
NURSING LONGTERM SHORTTERM NURSING DIAGNOSIS GOAL GOAL INTERVENTION
RATIONALE
EVALUATION
Impaired skin integrity r/t mechanical factors secondary to surgery.
>Monitored vital signs
To note changes and possible signs of complication and serves as a baseline data
>Monitored fluid intake and output.
To note fluid retention
>Assessed patient skin color, texture and turgor.
To assess extent of involvement
LONGTERM GOAL: After 5 days of nursing intervention the pt relatives was able to participate in prevention measures and treatment program.
>Instructed pt. relatives to keep area clean and dry
To prevent further complication
>Instructed patient to apply lotion
To maintain moisturize skin
>Instructed patients Family to provide optimum nutrition including vitamins and increase protein intake
To provide a positive nitrogen balance to aid in skin healing
>Encouraged patient to take multivitamins
To increase immunity
After 5 days of nursing intervention the pt relatives will be able to participate in prevention measures and treatment program.
After 8 hours of nursing intervention the patient relatives will be able to verbalize understanding of how to promote early healing of wound.
SHORTTERM GOAL: After 8 hours of nursing intervention the patient relatives was able to verbalized understanding of how to promote early healing of wound.
CUES O: 76 yrs old (+) Tracheostomy
NURSING DIAGNOSIS
LONGTERM GOAL
SHORTTERM GOAL
NURSING INTERVENTION
RATIONALE
EVALUATION
Risk for infection related to inadequate primary defense
After 5 days of nursing intervention the patient will be able to maintain good hygiene
After 4 hours of nursing intervention the patient relatives will be able to identify intervention that will prevent/reduce risk of infection of the patient
>Monitored vital signs
To note changes and possible signs of complication and serve as baseline data
LONGTERM GOAL: After 5 days of nursing intervention the patient was able to maintained good hygiene
>Assessed patient nutritional status including history of weight loss
Patients with poor nutritional status may be anergic, or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection.
>Instructed patient of daily bathing and hand washing
To reduce risk
>Encourage intake of protein- and calorierich foods.
This maintains optimal nutritional status.
>Encouraged patient to take vitamins such as vitamin C
To increase and strengthen immunity
SHORTTERM GOAL: After 4 hours of nursing intervention the patient relatives was able to identified intervention that will prevent/reduce risk of infection of the pt.
CUES
S; “ Inuubo pa rin siya.” Verbalized by the husband of the pt.
O; (+) productive cough (+)Wide eyed (+)Restlessness
NURSING DIAGNOSIS
LONGTERM GOAL
SHORTTERM GOAL
NURSING INTERVENTION
RATIONALE
EVALUATION
Ineffective airway clearance r/t excessive mucus secretions
In 5 days of nursing intervention the patient will be able to expectorate/ clear secretions readily
After rendering immediate nursing intervention the pt will be able to maintain airway patency
>Suction endotracheal
To clear airway when secretion are blocking airway.
LONGTERM GOAL: After rendering immediate nursing intervention the pt was able to maintain airway patency
>Elevated head of the bed, change position every 2 hours.
>Monitored vital sign
To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of ventilation to different lung segment. To note the any progress Lessen fatigue
>Provided opportunities for rest > istered O2 as needed
To provide airway
SHORTTERM GOAL: In 5 days of nursing intervention the patient was able to expectorate but not cleared the secretions readily
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