Review of System/Physical

Date: January 8, 2015 Time: 6:00 pm

Evaluated by: Mary Carolene Saur and Ylron John Tapar
System

ROS

Mode of
Assessment

Ideal

Observed

Thereshouldbenosignofpain.Appearance
iscleanandneatlydressedaccordingtothe
environment.Thepatientshouldexhibit
bodysymmetry.Noobviousdeformityanda
wellappearance.
Theskinvariesfromwhitishpinktobrown
colordependingonthepatientsrace.Skin
shouldbedrywithaminimumof
perspiration.Thenailsurfaceshouldbe
smoothandslightlyroundedorflat.Skin
shouldbedrywithminimumperspiration.

Nosignofpain.Appearanceis
cleanandneatlydressed.No
signofdiscomfort.

Nooccurrenceofswelling,
lesionsandtenderness.Patient
didntcomplainofanypain
duringpalpitation.
Eyesaresymmetrical;pupils
aredeepdark,andsclera
appearstobewhite.

A.General/Overall
HealthStatus

Okaynamanang
pakiramdamko.As
verbalizedbythepatient.

Inspection

B.Integument(skin,
hair,nail)

Walaakonararamdaman
nakakaibasabalatkoper
hindiakonakakapag
suklayngbuhok.As
verbalizedbythepatient.

Inspection

C.Head

Hindinasakitangulo
ko.Asverbalizedbythe
patient.

Inspectionand
palpitation.

Generallyroundandproportionaltothe
body.Noswelling,lesions,tendernessnoted
uponpalpation.

D.Eyes

Malinawnamanmga
matakoasverbalizedby
thepatient.

Inspectionand
palpation

Eyesareevenlyplaceandinlinewitheach
other.Scleraiswhite;conjunctivaispink.
Eyelidsshouldappearsymmetrical.The
pupilsshouldbecompletelyblack,round
andequaldiameter.

E.Ears

Walanamanproblemasa
pandinigko.as

Inspectionand
palpation

Patientshouldbeabletohearandrespond
welltoourquestions.Thepositionofthe

Patientsskinisdry.Nosign
ofalopeciabutdandruffor
flakesisvisiblefromhishead
andonhisshoulder.Nailbeds
arecleannosplinteringor
brittleedges.

Nopresenceofswellingor
anylesions.
Nopresenceofdischargeor
cloudiness.
Earsaresymmetricaland
theresnoappearanceof

Significance

Drynessofheadmaybecaused
bycoldair,combinedwith
overheatedroomswhichcan
causesitchiness.Notenough
shampooingmaycausethe
flakesorimproperuseof
shampoo.

verbalizedbythepatient.

earsshouldbeproportionaltothehead.

lesionsorskindiscoloration.
Theearpinnaisalignfromthe
outercanthusoftheeyetothe
occiput.
Thepatientdidnotcomplain
ofpainortendernessduring
palpation.

F.NoseandSinuses

Walanaakosipon.
Nakakahinganamanako
ngmaayosasverbalized
bythepatient.

Inspectionand
palpation

Noevidenceofswellingaroundthenose,
eyes,andsinuses.Locatedsymmetricallyin
themidlineoftheface.

Nostrilsarepatent;patientcan
performnormalbreathing.No
swellingortendernessfelt
duringpalpationatthesiteof
thesinuses.

G.MouthandThroat

Hindinamannangangati
lalamunanko,medyodry
langanglabiko.as
verbalizedbythepatient.

Inspection

Thelipsshouldbemoistandpinkwithno
evidenceoflesionsorinflammation.The
throatisnormallypinkandvascularand
withoutswellingorlesions.

Hindinamansumasakit
angleegko.as
verbalizedbythepatient.

Inspectionand
palpitation

Thereshouldnotbeanysignofmassand
lumps.Symmetricalandnodistention.

I.BreastandAxillary

Normallahat.as
verbalizedbythepatient.

Inspection
palpation

J.Respiratory

Maykontinguboparin
ako.asverbalizedbythe
patient.

Inspectionand
vitalsigns

Thepatientslipsareslightly
violetanddry.Theresnosign
ofinflammation.Thethroatis
pink;theresnosignof
inflammation.
Thepatientsneckisnormal
nonodulesandlesionsfound.
Nopainexperiencedduring
palpationoftheneck.
Breastissymmetry
nobreastedema
noswelling
nodischarges
nolesions
lympnodesarenotpalpable
lympnodesaremovable
nobarrelchest
nopectuscarinatum
nopectusexcavatum

H.Neck

Thereshouldnotbelumpsornodules.

Thereshouldbenodifficultyofbreathing.
Therespiratoryrateshouldbebetween12
20cyclesperminute.Nowheezing,

Lipsaredryfromdehydration,
whichisduetolackofoxygenin
theblood.

Cracklesareduetowater@the
lungparenchyma

difficultybreathingorchestpain.

nokyphosis
shouldersareinthesame
height
nomasses
nouseofaccessorymuscle
(+)sputumproduction
thinwaterysputum
(+)crackles
RR20

K.Cardiovascular

Medyomataasangblood
pressureko.as
verbalizedbythepatient.

Vitalsignsand
inspection

Bloodpressureshouldnotbeover120/80
andnotlowerthan90/60.Heartrateshould
rangearound60100beatsperminute.

Patienthasabloodpressureof
130/90.
Nopulsation@
aortic,pulmonic,tricuspid,mitra
l
Radialpulseispalpated

L.Gastrointestinal

Walanasakitsatyanko.
Asverbalizedbythe
patiet.

Inspectionand
Palpation

Itshouldbenopresenceoftendernessand
masses.

M.Urinary

Hindiakonahihirapan
umihi.Asverbalizedby
thepatient.

Inspectionand
patients
urinalysis
results.

Nodifficultyeliminationurine.Urinalysis
normalvalue:yellowcolor,clear,pHlevel
4.58,negativeproteinandglucose.

Theresnoretractions
forrespirationtheabdomen
riseduringinhalationandfalls
dungexhalation.
Nomassesornodules
presented
Patienthasanormalinputand
output.Urinalysiscameout
normalwiththeresultof
yellowurine,clear,pHlevel
of7.0.,negativeproteinand
glucoseintheurine.

N.Genitalia

Normallangdin.As
verbalizedbythepatient.

Inspection

Skinisfreeoflesionsandinflammation.No
abnormaldischargeormasses.

O.Musculoskeletal

Minsansumamasakit

Inspection

Muscleandjointsshouldnothavedifficulty

Theresnolesions,rashor
inflammation.Patientdenied
anyabnormaldischargeor
masses.
Kneehurtsafterwalkingor

Abnormalincreaseofblood
pressureisbecauseofthe
constrictionofthesmall
arterioles.

Duetodegenerativeprocessand

yungtuhodkopag
nakatayongmatagal.as
verbalizedbythepatient.
P.Neurologic

Q.Endocrine

R.Hematologic

moving.

Walanamanako
nararamdamanna
kakaiba.Asverbalized
bythepatient.
Walanamanako
nararamdamanna
symptomsngdiabetes.

Inspectionand
interview

Nohistoryofabnormalmotorfunction,
sensoryfunction,andmentalstatus.

Inspection

Hindinamanakomadali
magkabruiseo
magkasugatsabibig.As
verbalizedbythepatient.

Laboratory
Resultsand
inspection

NormalFindings:
WBC5.010
RBC4.05.5
Hemoglobin120160
Nobleedingtendencyofskinormucous
membrane,excessivebruising,lymphnodes
swelling,exposuretotoxicagentsor
radiation.

standingupforalongtime.
Nostiffness,swelling,cramps,
orweaknessisfeltinanypart
ofthebody.
Nohistoryofseizuredisorder,
stroke,faintingorblackouts.
Noabnormalitiesinthe
patientsmentalstatus.
Nosignsofabnormalities.

Patientappearstobenormal.
Noevidenceofabnormal
excessivethirst,hunger,or
urineproduction.Noabnormal
hairdistributionandnosigns
ofnervousness.

decreasemusclestrengthin
lowerextremitiesrelatedto
activityintolerance.

II. Laboratory Studies/ Diagnosis

July15,2015
Procedure

HbA1c

Indication

GlycatedHemoglobinor
Glycohemoglobinisatestthatshows
howwellyourdiabetesisbeing
controlled.Itisanaverageoftheblood
sugarcontroloverthepast2to3
monthsandisusedalongwithhome

Normalvalue/
Actual
Implication
Findings
Findings
CLINICALCHEMISTRYSECTIONBLOOD7/15/15
4.36.4%
6.4%
HemoglobinA1clevelsbetween4.3%to
6.4%,HemoglobinA1clevelsbetween
5.7%and6.4%indicateincreasedriskof
diabetes,andlevelsof6.5%ofhigher
indicatediabetes.

NursingResponsibilities

Takeasampleofbloodbyinsertinganeedle
intoaveininthearmorprickingthetipof
thefingerwithasmallpointedlancet.

bloodsugarmonitoringtomake
adjustmenttodiabetesmedicine.
CLINICALCHEMISTRYSECTIONBODYFLUIDS7/15/15
4105.90
7.71
Havingahigherlevelfastingblood
mmol/L
glucoseindicatesthatthepossibilityfor
youtohavediabetesisgreater.

Fastingblood
sugar

Patientmustfastfor8hours

Creatinine

Wasteproductfromthenormalbreakdown

58110mmol/L

102

SGPT
(SerumGlutamic
pyruvic
transaminase)

Itismeasuredtoseeiftheliverisdamaged
ordiseased.LowlevelsofSGPTare
normallyfoundintheblood.Butwhenliver
isdamagedordiseaseditreleasesSGPTin
thebloodstreamwhichmakesSGPTgoup.
Keeptrackoftheeffectsofmedicinesthat
candamagetheliver.
Thisistoidentifytheamountofcholesterol
thatisinyourbody.Highamountof
cholesterolcanbuildupinthewallsofthe
arteriesandhardens,
Highlevelsarebetter.LowHDL
cholesterolputyouinhigherriskforheart
disease.GoodcholesterolIttransport
cholesterolfrombloodtoliverwhereitis
secretedbythebody.
BadCholesterolThistestcanidentifythe
amountofplaquebuildup.Measurea
personsoverallriskofhavingaheartattack
orstroke.
Thebuildupoffattydepositsinarterywalls
thatincreasestheriskforheartattackand
stroke.

2172U/L

164
(2xdone)

Cholesterol

HighDensity
Lipoprotein

LowDensity
Lipoprotein

Triglycerides

Anormalresultofcreatininetestmeans
thekidneysareabsorbingthecreatinine
anditisclearedfromthebody.
AhighresultofSGPTtestmayindicate
thattheliverisverydamage.Thedamage
canbeduetotheamountofmedications
consumed,liverdisease,arrhosisand
hepatitis.

Cholesterollevelsarenormalwhich
meansthereisnoplaquebuildupinthe
arteries,whichlessenstheriskforheart
attackandstroke.
NormalHDLcanresulttolowriskof
havingheartdisease.ThemoreLDLthat
canbetransportedfrombloodtoliverto
beexcretedbythebody

>Explaintothepatientthathemay
experienceslightdiscomfort.
>Alertthepatientofthesymptomsor
hypoglycemia,weakness,nervousnessand
hunger.
>Tellpatientthatmedicationwillhavetobe
stoppedfor24hoursbeforetheprocedure.
>Checkurineoutputin24hours.
>Explaintheproceduretothepatient.
>Notifythepatientthatbloodwillbedrawn
fromvein;theremightbeamildbruising.

05.2
mmol/L

2.42

>Havecholesterolcheckevery5years.
Peoplewhoareatriskforheartattackmay
needtobecheckedmoreoften.

01.55mmol.L

0.84

03.9
mmol.L

1.33

NormalLDLresultcanindicatethat
thereslowamountofplaquebuildupin
thebody.ThelowertheLDLthebetter.

>Recommendtoavoidfoodhighinsaturated
fatsandtransfats.

01.69mmol/L

0.44

Lowamountoftriglyceridesisexpected
todecreasetheriskforheartattackor
stroke.Smallamountoftriglycerides
indicatesthatthereslowbuildupoffatty
depositinthearterywhichwillmakethe

>AdvicePatienttodecreasesugar
consumption,eatlowfatdiet,addomega3
fattyacidsintheirdietandexercisetoavoid
increaseleveloftriglycerides.

>ToHelpboostHDLadvicepatienttobe
active,loseextraweight,stopsmokingand
choosebetterfats.

Uricacid

Determineshowmuchuricacidispresent
inyourblood.Therestcanhelpdetermine
howwellyourbodyproducesandremoves
uricacid.

Color

Toassessouroverallhealthtodiagnose
medicalconditionandtomonitormedical
condition.
Determinesthefreshnessoftheurine.

Transparency

ReactionpH

Protein

Glucose

SpecificGravity

ThepHleveloftheurinecandetermineif
youhaveaninfection,ifalkaline,itcan
indicateinfection.
Proteinintheurinecanindicateproteinuria
somediseasethatcancausethisarerenal
disease,fever,CHF,HPNandothers.
Glucoselevelisimportanttoidentify
diabetes.Diabetesmaylowerorfalsethe
glucosetendsintheurine.
SpecificGravitywithincreasewiththe
amountofdissolvedparticlesinit.

RBC

RBCintheurinemayindicateinfectionor
inflammationoftheurinarytractinfection.

Epithelialcells

Inurinarytractconditionssuchas
infections,inflammationandmalignancies,
moreepithelialcellsarepresent.

Redbloodcells

IfRBCislow(anemia)Thebodymaynot
begettingtheoxygenitneeds.Ifitstoo
hightheresachancethatitwillclamp
togetherandblockthebloodvessels

bloodflownicely.
208506
350
PatientD.Vhasnormaluricacidwhich
ummol/L
meansitiseasilydissolvedintheblood,
filteredthroughthekidneysandexpelled
intheurine.
URINALYSISURINE7/15/15
Lightyellowto
Yellow
Yellowurineisnormal.
amberbrown
ClearorCloudy

Clear

4.58

7.0

0trace

Negative

0trace

Negative

>Advicepatienttorefrainfromanyfoodor
drinkforhoursbeforethetest.

>Askpatientiftakinganymedications,
vitamins,supplementsbecausesomedrugs
canaffecttheresultoftheurinalysis.

Freshlyvoidedurineistransparentor
clear.Cloudyurinemaybecausedby
crystals,deposits,whitecellsorredcells.
UrinePHlevelisatnormal,noinfection
occurs
Noproteinintheurine,whichmeansno
kidneydiseaseorkidneydamage.

Negativeglucoseintheproteinmay
indicatethatthepatientdoesnthave
diabetes.
1.005to1.125
1.015
Valvesthatremain1.010regardlessof
fluidintake,occursinchronic
glomerulonephritiswithextremerenal
damage.
03
02/HPF
NormalRBCcountcansimplifythatthe
patientdoesnothaveanyinflammationor
infection.
Rare
Rareamountofepithelialcellsimplies
thatthereislesschanceofinfectioninthe
urinarytract.
BODYFLUIDS7/15/15
4.506.00
5.20
TheresanormalamountofRBCinthe
x10^12/L
body,whichmayimplythatthebodyis
gettingtheconsistentamountofoxygenit
needs.

>Explaintheproceduretothepatient.
>Explainthepossibleresults.

Hematocrit

Hemoglobin

Whiteblood
Cells

Lymphocytes

Monocytes

Eosinophil

(Capillaries)
Measurestheamountofspace(volume)red
bloodcellstakeupintheblood.Showsif
anemiaorpolycythemiaispresent.
Measurestheamountofhemoglobinin
bloodandisagoodmeasureofthebloods
abilitytocarryoxygenthroughoutthebody.
Givesinformationabouttheimmune
system.Toomanyortoolowcanhelpfind
andinfection,anallergicortoxicreactionto
medicineorchemicals.
Crucialtotheimmunesystem.ThereareT
cells,Bcellsandkillercells.Thesecellsact
torecognizeantigensproducesantibodies,
oreventokillcellsthatcouldcause
damage.
Responsetoinflammationsignals,theycan
movequicklytositesofinfectioninthe
tissuesanddivideintomacrophagestoelicit
animmuneperson.
Helpprotectbodyfromharmfulbacteria,as
wellasinparasitesthatcanstealimportant
nutrientsfromyourbody.

0.400.54%

0.48

120.00
160.00g/L

157

4.5010.00x
10^9/L

6.9

0.200.40

0.38

0.000.07

0.10

0.000.05

0.06

Theresnormalamountofhematocrit,
whichmeansthepatientisnotsufferingof
anemiaorpolycythemia.
Theamountofhemoglobininthebloodis
normalwhichmakesoxygendistribution
throughoutthebodyeasy.
Thewhitebloodcellslevelisnormaland
thisimpliesthatthebodyisproducing
enoughWBCthatwillhelpfightoff
infections.
Theresanormalamountoflymphocytes
inthepatientsblood,whichwillhelpkill
cellsthatmaycausedamagetothebody.

Anincreasedpercentageofmonocytes
mayindicatechronicinflammatory
disease,parasitic,infection,tuberculosis
andviralinfection
Slightlyhighamountofeosinophilmay
implythattheresstress,inflammation,a
feverfromvirus,diseasethatresultsfrom
abnormalactivityoftheimmunesystem.

IV. Problem List

A. Actual or Active
Problem No.

Problem (Chief Complain)

Date Identified

Date Resolved

Ineffective Airway Clearance

July 16, 2015

July 16, 2015

Increase Blood Pressure

July 16, 2015

July 16, 2015

Self Care Deficit

July 16, 2015

July 16, 2015

A. High Risk or Potential

Problem No.

Problem

Date Identified

Risk for Activity Intolerance

July 16, 2015

Risk for Mild Anxiety

July 16, 2015

Risk for Fall

July 16, 2015

NCP: Ineffective Airway Clearance

Date: July 16, 2015

ASSESSMENT
Subjective:
Maykontingubo
parinako.as
verbalizedbythe
patient.

Objective:

Wheezing
Rapidand
shallow
breathing
Noisy
breathing
Coughevery
2minutes
Phlegm
production:
white,
wateryand
thin

NURSING
DIAGNOSIS
Ineffective
airway
clearance
relatedto
presenceof
phlegm
production.

INFERENCE

PLANNING

Theinflammation
andincreased
secretionsmakeit
difficultytomaintain
apatentairway,
whichiscausedby
decreaseabilityto
expeltheexcessive
mucousproduced
thatwillleadto
extensiveobstruction
oftheairway.

ST:
After6hoursofnursing
interventionthepatient
will:

Maintainairway
patency
Expectorate
secretionseasily
Demonstrate
reductionof
congestionwith
clearbreath
sounds,
noiseless
respiration
Demonstrate
behaviorsto
improveor
maintainclear
airway.

INTERVENTION

RATIONALE

Monitor
respirationsand
breathsounds
(eg.Wheezes)
Evaluate
patients
cough/gagreflex
andswallowing
ability.
Maintainhigh
backrestduring
restandsleep.

Indicationofrespiratory
distressand/oraccumulation
ofsecretion

Determinesabilitytoprotect
ownairway

Toopen/maintainopen
airwaywhenrestingand
sleeping

IncreaseOFI

Helpsinthinningof
secretionandeasier
expectoration
Liquefyviscoussecretion

Tomaximizeeffort

Toascertainstatusandnote
progress

Prevents/reducesfatigue

Encouragedeep
breathingand
coughing
exercises
Auscultate
breathsoundsto
identify
adventitious
sounds.
Encourage/provi
deopportunities
forrest

EVALUATION
ST:
After6hoursofnursing
interventionpatientwas
ableto:

Maintainairway
patency
Expectorate
secretionseasily
Demonstrate
reductionof
congestionwith
noiseless
respiration
Understandand
demonstrate
behaviorsto
improveor
maintainclear
airway.

NCP Increase Blood Pressure

Date: July 16, 2015
ASSESSMENT
Subjective:
Hindikoalam
batlagimataas
angblood
pressureko?as
verbalizedbythe
patient.

Objective:
Vitalsigns:

BP:130/90
mmHg
PR:84
bpm
20cpm
35.7C

Requestfor
information

NURSING
DIAGNOSIS

INFERENCE

Knowledge
deficitrelatedto
lackof
informationabout
thedisease
processandself
care.

Increaseblood
pressuremeanshigh
tensionintheartery.
Arteriesarevessels
thatcarrybloodfrom
thepumpingheartto
allthetissuesand
organsofthebody.
Normalblood
pressureisbelow
120/80;BPbetween
120/80and139/89is
called
prehypertensionand
bloodpressureof
140/90oraboveis
high.Theincreasein
bloodpressurecan
leadtomany
conditionslikeheart
disease,renaldisease
orstroke.

PLANNING
ST:

INTERVENTION

After6hoursof
nursing
intervention,the
patientwillbe
abletogain
knowledgeofhis
diseaseandshow
positive
response.
Understandand
perform
necessary
lifestylechanges
andparticipatein
treatment
regimen.

Ascertainlevelof
knowledge,including
anticipatoryneeds
Determineclientsability,
readinessandbarriersto
learning.
Defineandstatethelimitsof
desiredBP.Explain
hypertensionanditseffect
ontheheart,bloodvessels,
kidneyandbrain.
Assistpatientinidentifying
modifiedriskfactorslike
diethighinsodium,
saturatedfatsandcholesterol
Advicetohavecheckupsas
oftenasneededand
importanceoffollowing
treatmentregime.

Encouragepatientto
decreaseoreliminate
caffeine,sodaorchocolates.

Provideactiveroleforclient
inlearningprocess.

RATIONALE

Individualmaynotbe
physically,emotionally,
ormentallycapableat
thistime.

EVALUATION
ST:

Providesbasisto
understandhowBPcan
increase,clarifiesthat
increaseinBPcanexist
withoutsymptoms.
Thesefactorshasbeen
showntocontributeto
hypertension

Lackofcooperationis
commonreasonfor
failureof
antihypertensivetherapy.

Caffeineisacardiac
stimulantandmay
adverselyaffectcardiac
function

Promotessenseofcontrol
oversituationandis
meansfordetermining
theclientisassimilating

After6hours
ofnursing
intervention,
thepatient
gained
knowledge
aboutthis
health
conditionand
showeda
positive
attitude
towardsit.
Patientisable
toperform
lifestyle
changesin
participationto
histreatment
regimen.

Providemutualgoalsetting
andlearningcontracts.

andusingnew
information.
Clarifiesexpectationsof
teacherandlearner

NCP Lack of Proper Hygiene

Date: July 16, 2015
ASSESSMENT

NURSING
DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:
Hindipaako
nakakaligo
ngayongaraw.
Asverbalizedby
thepatient.

Objective:

Discomfort
Unfixed
hair
Presence
of
dandruffs
Drybody
skin

Selfcaredeficit
relatedtolackof
motivationin
performing
properhygiene.

Havinggoodhygiene
isessentialtolivea
healthylife.Washing
yourhands,cleaning
yourselfafteralong
daywillhelp
decreasetheriskof
gettingdisease,
infectionsand
bacteria.

ST:

After6hoursof
nursing
interventionthe
patientwill
identifyatleast3
reasonswhy
hygieneisan
importancetothe
health.
Verbalize
knowledgeof
healthcare
practices
Initiateand
performselfcare
activitieswithin
levelofown
ability

Explaintheimportanceof
properbathingandhair
brushingtothepatient

Performandassistwith
meetingclientsneedswhen
heisunabletomeethisown
needsforexamplepersonal
careassistance

Plantimeforlisteningtothe
clientsfeelingsandconcern

NCP Risk for Activity Intolerance

Toprovide
appropriatewayof
doingtheprocedure

ST:

Enhances
commitmenttoplan
andhelpspatientto
bemotivated

Todiscoverbarriers
toparticipationin
regimenandtowork
onproblemsolution.

After6hoursof
nursing
interventionthe
patientwasable
toidentify3
reasonswhy
properhygiene
isimportant.
Patientwasable
toverbalizehis
knowledgeof
thehealthcare
practices
Patientwasable
toperformself
careactivities
withinlevelof
ownability.

Date: July 16, 2015

ASSESSMENT
Subjective:
Hindinaako
masyado
nageexercise.as
verbalizedbythe
patient.

Objective:

NURSING
DIAGNOSIS

INFERENCE

Riskforactivity
intolerance
relatedto
prolongedbed
rest.

Mostactivity
intoleranceisrelated
togeneralized
weaknessand
deliberation
secondarytoacuteor
chronicillnessandor
disease.
Adequateexerciseis
importanttoprevent
gettingill.

PLANNING
ST:

Weaklower
extremities
Irritability
Facial
grimace
Vitalsigns

BP:130/90
PR:84bpm
RR:20cpm
T:35.7C

Regularphysical
activitywillhelp
controlourweight,
improveourmood,
boostsenergy,and
promotesbetter
sleep.
Lackofphysical
activitycanleadto
obesity.

INTERVENTION
INDIVIDUAL:

Participate
willinglyin
necessary/desired
activities
Verbalize
understandingof
potentiallossof
abilityinrelation
toexisting
condition
Identify
alternativeways
tomaintain
desiredactivity
level.

Askpatientaboutusuallevel
ofenergy

EncourageactiveROM
exercises
Providepositiveatmosphere
whileacknowledging
difficultyofthesituationfor
patient
Determinecurrentleveland
physicalconditionwith
observation,exercise
tolerance
Discusswithpatientthe
relationshipofillnessor
debilitatingcondition

COLLABORATIVE:

Implementphysical
therapy/exerciseprogramin
conjunctionwiththeclient
andotherteammembersfor
examplephysicalandor
occupationaltherapist.

RATIONALE
INDIVIDUAL:

Toidentifypotential
problemsand/orpatients
perceptionofenergyand
abilitytoperformneeded
ordesiredactivities
Tomaintainmuscle
strengthandjointROM
Helpsminimize
frustrationsandincrease
energy

EXPECTED
OUTCOME
ST:

Providesbaselinefor
comparisonand
opportunitytotrack
changes.
Understandingthese
relationshipscanhelp
withacceptanceof
limitations.
COLLABORATIVE:

Coordinationof
programincreases
likelihoodofsuccess.

Patientwillbe
ableto
participate
willinglyin
desired
activities
Patientwill
verbalizehis
understanding
aboutpotential
lossofability
inrelationto
existing
condition
Patientwill
identify
alternative
waysto
maintain
desiredactivity
level.

NCP Risk for Mild Anxiety

Date: July 16, 2015
ASSESSMENT
Subjective:
Hindikona
nakikitayungmga
anakko.As
verbalizedbythe
patient.
Objective:

Irritability
Stressed
Worried
Expressed
concerns
dueto
changein
lifeevents.
Drylips
Sleep
disturbance

NURSING
DIAGNOSIS
Riskformild
anxietyrelated
tolossof
presencefrom
thefamily
members.

INFERENCE
Vagueuneasyfeeling
ofdiscomfortor
dreadaccompanied
byanautonomic
response(thesource
oftennonspecificor
unknowntothe
individual);afeeling
ofapprehension
causedby
anticipationof
danger.Itisan
alteringsignalthat
warnsofimpending
dangerandenables
theindividualtotake
measurestodeal
withthreat.

PLANNING
ST:

INTERVENTION
INDIVIDUAL:

Appearrelaxed
andreportthat
anxietyreduced
toamanageable
level
Verbalize
awarenessof
feelingsof
anxiety
Demonstrate
problemsolving
skills
Use
resources/support
system
effectively

Provideaccurate
informationaboutthe
situation
Listenhelpfulresourcesand
peopleincludingavailable
hotlineorcrisismanager.
Reviewstrategies,suchas
roleplayinganduseof
visualizationstopractice
anticipatedevents.
Encouragepatientto
developandexerciseor
activityprogram
Provideopportunitiesforthe
patienttomakesimple
decision
Encourageexpressionsof
feelings(fear,sadness,etc.)
acknowledgeanxiety.
Providecalm,peaceful
settingandprivacyas
appropriate.

RATIONALE
INDIVIDUAL:

Helpsclientidentify
whatisrealitybased.
Toprovide
ongoing/timely
support
Usefulforbeing
preparedfor/dealing
withanxiety
provokingsituations
Maysavetoreduce
levelofanxietyby
relievingtension
Enhancessenseof
control
Enhancestrustand
therapeutic
relationship
Promotesrelaxation
andabilitytodeal
withsituations.

EXPECTED
OUTCOME
ST:

Patientwillbe
abletobe
relaxedandat
ease,
verbalized
feelingsof
anxiety,
demonstrate
problem
solvingskills
anduse
resources
system
effectively.

NCP Risk for Fall

Date: July 16, 2015
ASSESSMENT
Subjective:

Objective:

Lowered
siderails
Irritable
Decreased
lower
extremity
strength
Limited
ROM

NURSING
DIAGNOSIS
Riskforfalls
relatedto
impaired
physical
mobility.

INFERENCE
Increase
susceptibilityto
fallingthatmay
causephysicalharm.

PLANNING
ST:

INTERVENTION
INDIVIDUAL:

Verbalize
understandingof
individualrisk
factorsthat
contributeto
possibilityof
falling.
Modify
environmentas
indicatedto
enhancesafety
Befreeofinjury

INDIVIDUAL:

Assessmusclestraight,
grossandfinemotor
coordination
Reviewhistoryofpriorfalls
Advicepatienttoalways
keepsiderailsup
Assessmood,coping
abilities,personallystyles

COLLABORATIVE:

RATIONALE

Refertorehabteam,
physicaloroccupational
therapistasappropriate

Topredictcurrent
riskforfalls

Promotesafety

Individualsand
temperamenttypical
behavior,stressors,
andlevelofself
esteemcanaffect
attitudetowards
safetyissues,
resultingin
carelessnessor
increasedrisktaking
withoutconsideration
ofconsequences.

COLLABORATIVE:

Toimprovepatients
balance,strengthor
mobility.

EXPECTED
OUTCOME
ST:

Patientwillbe
ableto
verbalizehis
understanding
abouttherisk
factorsthat
contributesto
thepossibility
offalls.
Patientwillbe
abletoavoid
injury.

Discharge Health Teaching Plans

COMPLIANCE
Medication

CONTENT
Advice patient to take blood pressure medications exactly as directed. Dont skip doses. Missing doses can cause your blood pressure to get out of
control.
Avoid medications that contain heart stimulants, including over the counter drugs. Check for warnings about high blood pressure on the label.

 Check with your doctor before taking decongestant some decongestants can worsen high blood pressure.
Always take your antibiotics as directed.
Explain the side affects of the medication and state their importance.
Environment

Treatment

Health teaching

Out-patient

Diet

Encourage patient to provide adequate rest periods and observe and promote personal hygiene.
Instruct patient not to do strenuous activity for him to gain back his normal strength.
Advice patient to maintain a healthy weight. Exercise at least three hours in a week.
Recommend patient to breath warm and moist air to help loosen mucus. Loosely place a warm; we wash cloth over your nose and mouth.
Continue taking medications as directed.
Take deep breaths. Deep breathes help open the airway. Take two deep breaths and cough two or three times every hour. Coughing helps get mucus
out of the body.
Drink liquids as directed. Liquids help make mucus thin and easier to get out of your body.
Advice patient to lay with their head lower that the chest several times a day and tap the chest area to help loosen mucus.
Advice patient to get at least eight hours of sleep every night.
Avoid heavy lifting and strenuous activities after discharge.
Recommend to patient to control their stress by doing stress management techniques. This will help decrees high blood pressure.
Demonstrate and explain hand-washing procedure to decrease the risk of acquiring bacteria.
Further inpatient care includes monitoring of changes in vital signs, mucous production, and reinforcement of dietary advice, practice energy-saving
techniques and so simple activities.
Have regular check ups to monitor progress of heath and wellness.
Encourage patients to consult doctor or go to the nearest hospital if theres any problem.
Recommend DASH diet to reduce hypertension.
Advice to cut back on salt and canned foods.
Limit alcohol consumption and limit drinks that contain caffeine.
Eat foods riche in vitamin C and increase fluid intake.