ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION INTERVENTION EVALUATION

KNOWLEDGE
In the entire process of 1. Prepare and Assist for NG Tube 1. To provide route for enteric In the entire process of
OBJECTIVE SELF CARE DEFICIT : HYPERTENTSION nursing interventions, The insertion. nutrition. nursing interventions, The
HYGIENE, DRESSING ˇ patient should meet ALL patient has met all self
PATIENT IS AND GROOMING, OCCLUSION WITHIN self care requirements as 2, Provide enteric nutrition VIA NG 2. To meet patient’s need for an care requirements
UNABLE TO: FEEDING AND VESSELS OF THE necessary. The patient is Tube feeding. High fowlers for at adequate nutritional intake. necessary. all SELF CARE
TOILETING BRAIN PARENCHYMA WHOLLY COMPENSATORY least 15 minutes after feeding. [ICU Setting] REQUISITES
[HYGIENE] ˇ and therefore, ALL SELF are performed by the
R/T DISRUPTION OF CARE [ICU Setting] 3. Careful I/O Monitoring and apply 3. To establish careful assessment on nurse. Patient met all
ACCESS AND BLOOD SUPPLY IN REQUISITES are to be necessary dietary restrictions. patients fluid and electrolyte balance. therapeutic self care
PREPARE BATH NEUROMUSCULAR THE BRAIN AREA performed by the nurse. demands in a complete
SUPPLIES IMPAIRMENT ˇ Patient should meet all 4. Change position at least ONCE 4. To prevent decubitus ulcerations. absence of self care agency
TISSUE AND CELL therapeutic self care every two hours or more often when
WASH BODY SECONDARY TO NECROSIS demands in a complete needed.
ˇ absence of self care
CONTROL CEREBROVASCULAR DESTRUCTION OF agency 5. Provide padding for the elbows, 5. To protect the patient’s skin
WASHING ACCIDENT NEUROMUSCULAR needs, ankles and other areas for integrity maintaining his first line of AEB
MEDIUMS JUNCTIONS AEB possible skin abrasion. defense against sickness and
ˇ infection. ABSENCE OF S&S OF
[DRESSING AND INTERRUPTION IN ABSENCE OF S&S OF NUTRITIONAL DEFICIT.
GROOMING] TRANSPORTATION OF NUTRITIONAL DEFICIT. 6. Prepare and Do catheterization. 6. To carefully measure output as [Adequate nutritional
ELECTRICAL [Adequate nutritional well as prevent frequent changing of intake]
OBTAIN ARTICLES IMPULSES TO THE intake] diaper that will disrupt patient’s
FOR CLOTHING NEUROMUSCULAR comfort and rest. GOOD SKIN TURGOR,
RECEPTORS GOOD SKIN TURGOR, NORMAL URINE OUTPUT,
PUT ON CLOTHES ˇ NORMAL URINE OUTPUT, 7. An adult diaper should be WORN 7. To prevent soiling of bed sheets, ABSENCE OF EDEMA,
MYALGIA/QUADRI OR ABSENCE OF EDEMA, at all times. Change the diaper as clothes and linens providing HYPER AND HYPOVOLEMIA
MAINTAIN HEMIPLEGIA HYPER AND HYPOVOLEMIA soon as patient defecated. maximum comfort and prevention of [Fluid and Electrolyte
APPEARANCE AT [Fluid and Electrolyte skin irritation if feces remains in balance]
AN ACCEPTABLE balance] contact with the patient’s skin for a
LEVEL long time. ABSENCE OF DECUBUTIS
ABSENCE OF DECUBITUS ULCERS AND FOUL ODORS
[FEEDING] ULCERS AND FOUL ODORS 8. Promote An Environment 8. To conserve energy promoting rest IN BETWEEN
IN BETWEEN conducive to rest and recovery. and recovery. LINENS/CLOTHING AND
PREPARE/OBTAIN LINENS/CLOTHING AND Decrease stimuli and Metabolic SKIN [Clean, Intact skin
FOODS FOR SKIN [Clean, Intact skin demand of the body. and mucus membrane]
INGESTION and mucus membrane]
9. Passive ROM Exercises Early 9. This is to improve circulation, ABSENCE OF ABDOMINAL
HANDLE UTENSILS ABSENCE OF ABDOMINAL morning once a day, 10 times reducing the risk of atheromatous AND BLADDER
AND BLADDER targeting both upper and lower formation. DISTENTION, RECTAL
BRING FOOD TO DISTENTION, RECTAL extremities. FULLNESS AND PRESSURE,
THE MOUTH FULLNESS AND PRESSURE, PAIN IN DEFECATION [
PAIN IN DEFECATION [ 10. Lastly, Do health teaching when 10. To educate the patient what Meeting toileting demands
CHEW AND Meeting toileting demands patient is at the optimum level to factors have contributed to his illness ]
SWALLOW FOOD ] receive information. and educating him to decrease, if not
totally eliminate those contributory PATIENTS VERBALIZATION
PICK UP GLASS PATIENTS VERBALIZATION factors to prevent recurrence of the OF COMFORT [ Epitome of
OF COMFORT [ Epitome of disease and promote change for a the nursing goal ]
[TOILETING] the nursing goal ] healthy lifestyle.

GO TO THE TOILET

BASED ON DOROTHEA
OREM’S SELF CARE
DEFICIT THEORY.

By : Budek