DATE AND TIME F E B R U A R Y 23, 2 0 1 2 @11pm

CUES Objective: Nvs of : 5/6 Assistive level scale of:4

0Completely independent 1Requires use of equipment or device 2Requires help from another person for assistance, supervision, or teaching 3Requires help from another person and equipment device 4Dependent, does not participate in activity

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 P A T T E R N

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

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

Depending on the
area and side of the cerebrum affected by the stroke, any, or all, of the following body functions may be impaired: 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

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 patients 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

patients 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 Frances. Nursing Care Plan. F.A. Davis company: Thailand. Copyright 2002. Doenges, Marilyn E. et al. Nurses Pocket Guide. F.A. Davis Company: Philadelphia. Copyright 2004. Gulanick, Meg et al. Nursing Care Plan 2nd edition. Mosby dedicated to publishing excellence: USA. Copyright 2000. Moorhouse, Mary Frances et.al . Nursing Care Plan. Copyright 2002. Sparks, Shiela M., RN, DNSc, C$ and Taylor, Cynthia M., RN, MS, CS, CNAA. Nursing Diagnosis Reference Manual 2nd edition. Copyright 1993.