NCP # 1

HUMAN NURSING RESPONSE DIAGNOSIS PATTERN E >Difficulty of breathing X related to compression of C the diaphragm H A N G I N G >Provide health teaching on proper deep breathing exercise O>Anxious >Diaphoretic >Uses the accessory muscles when breathing >Flaring of nares noted AMB PATHO CLIENT OUTCOME >Within the shift patient will be able to maintain patent airway for easy breathing INTERVENTION RATIONALE EVALUATION

S> Nahihirapan sya maghinga, sabi ni doc puwede dw n fahil sa pglaki ng atay niya kaya naiipit ang diaphragm niya kaya hindi makaexpand ng maayos ang baga niya as verbalize by mother.

Liver dysfunction

Hypertrophy of the liver

>Assisted in placing >This is done to facilitate easy patient in moderate high breathing and maximum expansion back rest. of the lungs and chest walls. >Monitor patient closely for any signs of compromised breathing. >Monitoring patient closely facilitates fast implementation of nursing intervention such as administering oxygen upon detecting respiratory distress. >Lying flat on bed compresses the chest wall therefore restricts maximum lung expansion and oxygen consumption. >Rest and sleep facilitates fast recovery and will decrease the oxygen demand of the body therefore it decreases the difficulty in breathing. >Deep breathing exercises facilitates good expansion of the lungs and helps cope in the oxygen deficiency brought by the difficulty in breathing.

Depression of the diaphragm

Decreased maximum chest expansion >Instruct mother to avoid placing the patient flat on bed when lying. >Encourage mother to provide patient with adequate rest and sleep.

>Goal met, patient was able to maintain good airway and verbalizes Hindi na po ako nahihirapan maghinga masyado. Hindi tulad kaninang umaga

Difficulty of breathing

NCP # 2
HUMAN NURSING RESPONSE DIAGNOSIS PATTERN E >Imbalance nutrition less X than body requirement C related to decreased H appettite A N G I N G >Advise mother to prepare foods that are pleasing to patients eyes. >Foods that are healthy and well prepared increases patients appetite. O>Thin appearance >Weak >Weight loss >Poor muscle tone >Lack of interest in food AMB PATHO CLIENT OUTCOME INTERVENTION RATIONALE EVALUATION

S> Pumayat talaga siya, dati kasi may katabaan siya. Ngayon kasi payat na siya tapos ang tiyan niya lang ang malaki as verbalized by mother.

>Within 2-3 hours of nursing Abnormal imbalances in blood intervention patient will be contents able to manifest Impaired proper understanding functioning of the of the blood importance of good nutrition. Decreased nutrient distribution

Blood dyscrasia

>Provide patient with health teaching on the importance of proper nutrition >Encourage mother to provide patient with healthy foods such as fruits and vegetables. >Encourage mother to provide patient with adequate rest and sleep periods. >Encourage mother to increase patients oral fluid intake.

>Teaching the patient on the importance of proper nutrition and its role in the body will help in gaining patients cooperation. >Having a good diet helps in fast recovery and improving patients nutrition status and boost patients immune system. >Adequate rest and sleep aids in fast recovery and strengthens the body.

Goal met, patient and her mother was able to understand the importance of proper nutrition and verbalized Tama, kaylangan talaga niya maging malusog para madali siya gumaling

Deficient nutrition

>Increased oral fluid intake improves patients hydration and condition.

NCP # 3

HUMAN NURSING RESPONSE DIAGNOSIS PATTERN C > Ineffective coping H mechanism r/t chronic disease O and complex self-care O regimen S I N G

AMB

PATHO

CLIENT OUTCOME >Within 4-5 hours of nursing intervention patient will be express acceptance of having difficulty in coping to current condition and ways on how to correct coping mechanism.

INTERVENTION

RATIONALE

EVALUATION

S> oo nahihirapan siya, hind na siya nakakapag-aral atsaka nahihiya siya sa mga kaibigan niya pati sa ibang tao. Minsan naiiyak as verbalized by mother O>Shy >Silent >Sadness noted >Anxious >Denial noted

Blood dyscrasia

Hypertrophy of the heart, liver, and spleen

>Discuss patients previous coping strategies and skills that have had worked and had positive effects. >Encourage patient to verbalize feelings and concerns. >Relieve anxiety by giving of appropriate information about blood dyscrasia. >Encourage patient to express concerns, feelings or fear openly. >Encourage family to provide patient with emotional support.

>to aid in identifying previous coping mechanisms and establishing effective coping strategies with the patient.

Body image alterations

Hospitalization

>Goal met, patient mood was improved dramatically. nagaimprove na man siya kasi masayahin na. >This is done to enlighten the feeling Atsaka hindi na of the patient and helping her cope masyado mahiyain with the fact that about her as verbalized by amputated leg. mother. >Providing appropriate information about the disease can help in alleviating anxiety of the patient >Also to help in alleviating anxiety and to aid in nurse monitoring of patients condition >Such disorder is not easy to handle specially at the young age of our patient. Providing her with emotional support is the best way of helping her cope with the present situation. >Diversional activities diverts the attention of the patient and helps in relaxation and alleviation of anxiety and tension.

Social isolation

Difficulty coping with present condition

>Advise patient to do some diversional activities such as listening to music

NCP # 4

HUMAN NURSING RESPONSE DIAGNOSIS PATTERN P >Disturbed body image E related to enlargement of R body part C E P T I O N

AMB

PATHO

CLIENT OUTCOME >Within 2-3 hours of nursing intervention patient will be express positive perception regarding her own image.

INTERVENTION

RATIONALE

EVALUATION

S> Lumaki iyang tiyan niya. Hindi man yan ganyan dati as verbalized O>Sadness noted >Anxious >Hesitant >Enlargement on the left lumbar region of the abdomen

Blood dyscrasia

Hypertrophy of the heart, liver, and spleen

>Encourage patient to verbalize feelings and concerns. >Encourage family to show their care and presence and support to the patient.

>This is done to enlighten the feeling of the patient and helping her cope with the fact that about her amputated leg. >Accepting reality of loosing a particular part of our body is not an easy thing to do, this is the time when the actual present and support of the family is very important to the patient.

Body image alterations

>Goal met, patient was able to express positive perceptio of herself and verbalized ok na man din ako, medyo nahihiya lang. as verbalized

>Explore the strength of >Exploring patients strength will the patients help the patient and the nurse personality. identify areas in which the patient can be better even in her present condition, this will also help in boasting patients, self esteem. >Encourage to do some diversional activity such as listening to mellow music. >Ecourage to take adequate rest and sleep periods >Diverting patients attention helps in alleviating her anxiety towards her own image. It also helps in the relaxation of the patient. >This is done to help patient recover faster, adequate sleep also provides patient with energy and promotes wound healing it also creates an atmosphere that is conducive for expressing patients emotion.

NCP # 5

HUMAN NURSING RESPONSE DIAGNOSIS PATTERN E >Fatigue related to X decreased perfusion C secondary to blood dyscrasia H A N G I N G

AMB

PATHO

CLIENT OUTCOME

INTERVENTION

RATIONALE

EVALUATION

S> Madali siya mapagod ngayon, hindi tulad dati as verbalized O>Weak >Thin appearance >Easy to tire >Diaphoretic

>Within 2-3 hours of nursing Abnormal imbalances in blood intervention patient will be contents regain strength and rest Impaired proper periods functioning of the blood

Blood dyscrasia

>Encourage mother to provide patient with adequate rest and sleep periods. >Encourage deep breathing exercises. >Provided health teaching on proper ROM exercises.

>Adequate rest and sleep periods helps in physical coping mechanism of the body to compensate for the decreased oxygen distribution. >Deep breathing exercises has many benefits including compensation for the decreased oxygen circulation of the body. >ROM exercises helps in improving the blood circulation of the body therefore allowing easy circulation of the blood to deliver as much oxygen as needed. > Having a good diet helps in fast recovery and improving patients nutrition status and boost patients immune system. >Relaxation is a good way of conserving energy and a good way to fight off fatigue together with proper rest.

>Goal met, patient was able to take adequate rest and sleep periods. Opo nakapahinga naman siya ng maayos

Decreased oxygen distribution

Deficit oxygen to different parts of the body

Fatigability

>Encourage mother to provide patient with healthy foods such as fruits and vegetables. >Encourage mother to decrease environmental stimuli to facilitate relaxation

NCP
Name of the Student: Eriquez, Paulo Luis L. CI:

Name of the Patient: Pajiji, Mohammad Age/Sex: 62 yrs. Old / M AP: Dr. Dickson Lao Diagnosis: Acute Peptic Ulcer Disease HUMAN NURSING AMB RESPONSE DIAGNOSIS PATTERN E >Acute pain > masakit parin ang X related to the tiyan ko pati likod as C effect of gastric verbalized, H acid secretion abdominal guarding A on damaged noted, facial grimace N tissue G I N G

Date: August 15, 2011

PATHO >It is frequently referred as a gastric, duodenal, or esophageal ulcer. It is caused by erosion of circumscribed area of mucous membrane. In addition, excessive increase in HCL in the stomach may contribute to the formation of gastric ulcer, and stress may be associated in its increased secretion.

CLIENT OUTCOME >within 8 hrs of nursing intervention, patients abdominal pain will decrease / eliminated

INTERVENTION >relieve pain by giving of prescribed medications >encourage to avoid foods and beverages that contains caffeine >relieve anxiety by giving of appropriate information about peptic ulcer

RATIONALE >to help in fast recovery of the patient and aid in relieving pain >foods and beverages with caffeine can cause irritation of the stomach >pts with peptic ulcer are usually anxious but not always obvious, providing appropriate information about the disease can help in alleviating anxiety of the patient >also to help in alleviating anxiety and to aid in nurse monitoring of patients condition >relaxation may enhance the decrease production of Hydrochloric acid which may be caused by anxiety

EVALUATION >Advise to do ROM exercises on none affected extremities and other parts of the body >to facilitate proper circulation of blood and avoid muscle wasting >Listen to the feelings and concern of the patient >to facilitate proper circulation of blood and avoid muscle wasting

>encourage patient to express concerns, feelings or fear openly >encourage patient to take enough rest and sleep

NCP
Name of the Student: Eriquez, Paulo Luis L. Diagnosis: Diabetes Mellitus CI: Sir Jay Tillo, RN

HUMAN RESPONSE PATTERN

NURSING DIAGNOSIS > Ineffective coping mechanism r/t chronic disease and complex self-care regimen

AMB > ano na ang gagawin ko ngayong may Diabetes n ako as verbalized, restless, troubled, anxious, >

PATHO

CLIENT OUTCOME >within the shift patient will be able to manifest signs of effective coping mechanism

INTERVENTION > Discuss with the patient the effects of diabetes on lifestyle, and way of living. >Discuss patients previous coping strategies and skills that have had worked and had positive effects. >relieve anxiety by giving of appropriate information about peptic ulcer >encourage patient to express concerns, feelings or fear openly >encourage family to provide patient with emotional support

RATIONALE >for better understanding of patients feelings and concerns >to aid in establishing effective coping strategies with the patient

EVALUATION

> providing appropriate information about the disease can help in alleviating anxiety of the patient >also to help in alleviating anxiety and to aid in nurse monitoring of patients condition >providing patient with family support facilitates patients drive to achieve our goal