Professional Documents
Culture Documents
NCP
NCP
CUES
S: NURSING
HEALTH HISTORY
- 58 years old
male
- Lifestyle: smoker
& alcohol drinker
occasionally
O:
Vital signs:
Temp:
36.7 C
PR: 68
bpm
RR: b19
cpm
BP: 120/80
mmHg
(+) tracheostomy,
midline neck
(+) incision @
mandibular region
(+)wound healing
NURSING
DIAGNOSIS
Risk for
infection
SCIENTIFIC
RATIONALE
Presence of
incisions and
wound healing
Microorganism
invades the
incision and
wound
Activation of body
defenses
Inflammation
NURSING INTERVENTIONS
GOAL:
By the end of the duty,
patient will demonstrate
no signs of infection.
During nursing
intervention, the student
nurse will:
OBJECTIVES:
By the end of the
nursing intervention,
the client will:
1. Not develop further
breaks from primary
defenses
2. Achieve timely wound
healing with no
infection.
3. Identify techniques to
prevent skin infection
Decrease in
monocyte status
Low immune
system
RATIONALE
EVALUATION
8. Techniques to prevent
or reduce risk of infection,
increase immune system
and to initialize learning
of patient.
S: Nahihirapan
siya ngumuya
kaya madalas
konti lang ang
nakakain niya as
verbalized by the
significant other
O: PHYSICAL
EXAMINATION
Vital signs:
Temp: 36.7 C
36.7 C
PR: 68 bpm
RR: b19 cpm
BP: 120/80 mmHg
- Difficulty in
swallowing
-Skin- Smooth,
dry skin with fair
turgor
- (+) muscle
wasting
Pale conjuctiva
Imbalanced
Nutrition:
Less than
Body
Requireme
nts related
to
decreased
intake and
secondary
to difficulty
swallowing
Presence of
incision @ left
mandibular &
sensation in the
throat
Difficulty of
swallowing
Decreased intake
Imbalanced
Nutrition: Less
than Body
Requirements
1. To initiate learning.
2. To provide ongoing
support and increase
likelihood of
accomplishing dietary
goals.
3. Foods preferred, well
tolerated, and high in
calories and protein
maintain nutritional status
during periods of
increased metabolic
demand.
4.Fluids are necessary to
eliminate wastes and
prevent dehydration.
Increased fluids with
meals can lead to early
satiety.
5. Smaller more frequent
meals are better tolerated
because early satiety
does not occur
6. A quiet environment
promotes relaxation.
Social interaction at
mealtime increases
appetite.
10.Encourage to verbalize
understanding of the
treatment plan for client.
3.Verbalized
understanding of
the need for
lifestyle
modifications of
patient
4.Demonstrated
progressive
weight gain
toward goal.
S: Hindi siya
nakakapagsalita
as verbalized by
the significant
other
O: PHYSICAL
EXAMINATION
Vital signs:
Temp: 36.7 C
36.7 C
PR: 68 bpm
RR: b19 cpm
BP: 120/80 mmHg
- (+) loss voice
-(+)tracheostomy
Impaired
Verbal
Communic
ation
related to
deficit
anatomy
and
physical
barriers
(tracheoto
my tube).
1. Another problem
affecting the choice plan
for communication.
1. Used and
Identified other
communication
method such as
board and pencil.
2. Will not
experience
frustration and
stress.
3. Will maintain
normal life and
continue to
communicate
with others.
4. Will have
encouragement
and hope for the
future.
S: NURSING
HEALTH HISTORY
- 68 years old
male
- Lifestyle: smoker
& alcohol drinker,
occasionally.
- Radiation
therapy
O: PHYSICAL
EXAMINATION
Vital signs:
Temp: 36.7 C
36.7 C
PR: 68 bpm
RR: b19 cpm
BP: 120/80 mmHg
- (+)
tracheostomy,
midline, neck.
- Hoarse/slurred
speech
- Coherent,
oriented to time
person and place
Readiness
for
Enhanced
Coping
During nursing
intervention, the student
nurse will:
NIC: Coping Enhancement
1. Review extent of
feelings of anxiety.
2. Discuss indication and
method of treatment
3. Assess presence of
positive coping skills/inner
strengths e.g (use of
relaxation techniques,
willingness to express
feelings, use of support
systems).
4. Encourage patient to
talk about what is
happening at this time and
what has occurred to
precipitate feelings of
anxiety.
5. Evaluate ability to
understand events and
correct misconceptions by
providing factual
information.