N- Self Care Deficit b14

DATE AND TIME F E B R U A R Y 23, 2 0 1 2

CUES Objective:  Nvs of : 5/6  Assistive level scale of:4 0—Completely independent 1—Requires use of equipment or device 2—Requires help from another person for assistance, supervision, or teaching 3—Requires help from another person and equipment device 4—Dependent, does not participate in activity

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@11pm   

Attached to a mechanical ventilator with a setting of With anti-embolic stockings on both lower extremities Diagnosis of: brainstem and cerebellar infarct Staff nurses are the one who is providing total physical care to the patient

HEALTH NEED A C T I V I T Y E X E R C I S E

NURSING DIAGNOSIS Self-care deficit related to impairment in neurologic function secondary to brainstem and cerebellar infarct.

a. clean fingernails  Depending on the area and side of the cerebrum affected by the stroke, any, or all, of the following body functions may be impaired: 

P A T T E R N

OBJECTIVE OF NURSING CARE INTERVENTION That within 8 a. assess for the hours span of care patient’s need my patient will  to know on have maintain what procedure proper grooming the nurse should as evidence by: do to the patient

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movement and sensation speech and language eating and swallowing vision cognitive (thinking, reasoning, judgment and memory) ability perception and orientation to surroundings

b. fixed hair c. clean gown d. absence of foul odor e. morning care provided

b.do hand washing before hadling the patient to prevent the spread of microorganism c. provide suctioning to the patient whenever there are secretions. secretions can contribute to the patient’s unhygienic state. d. Change wet and dirty clothes with clean one.  Clean clothing will make the patient feel comfortable.

EVALUATION February 24, 2012 @ 7am GOAL MET Patirnt was able to have proper hygiene as evidenced by:    

Absent of foul odor. Wearing clean clothes Hair well combed and tie. Clean fingernails and good to look.

   

self-care ability bowel and bladder control emotional control sexual ability

source: The Ohio State University Wexner Medical Center. 410 W. 10th Ave., Columbus, OH 43210

e. Comb hair  Well comb hair will make the patient look good even though she is lying and unconscious. f. wipe patient’s face when sebum accumulate the face secretes natural oil that may make the patient looks untidy g. turn the patient to sides regularly it may help the patient feel comfortable and helps the nurse assess the other part of the body. h. Cut and clean fingernails.  Dirty fingernails will result to further infection to

patient’s body. i.Provide proper oral care to patient  reduces halitosis and prevents mouth ulceration j.Provide complete bed bath to patient to make the patient feel comfortable and looks tidy.

BIBLIOGRAPHY: 

Doenges, Marilyn E. & Moorhouse, Mary s. Nursing Care Plan. F.A. Davis company: Thailand. Copyright 2002.

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Doenges, Marilyn E. et al. Nurse’s Pocket Guide. F.A. Davis Company: Philadelphia. Copyright 2004.

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Gulanick, Meg et al. Nursing Care Plan 2nd edition. Mosby dedicated to publishing excellence: USA. Copyright 2000.

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Moorhouse, Mary s et.al . Nursing Care Plan. Copyright 2002.

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Sparks, Shiela M., RN, DNSc, C$ and Taylor, Cynthia M., RN, MS, CS, CNAA. Nursing Diagnosis Reference Manual 2nd edition. Copyright 1993.