Ncp.2

for educational purpose only..

1. IX. NCP

June 27, 2014
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


SUBJECTIVE:
"hindi ko alam
kung
makakapagtrabaho
na ako kaagad
pagkagaling ko eh"
as verbalized by the
patient

OBJECTIVES:
-Vital signs,
BP130/90
Temp.36.2c
CR- 64
RR-20
-restlessness
-difficulty in
sleeping
-fatigue









Anxiety related to
threat to/ or change in
health status


Within 8 hours of
nursing
interventions the
patient will appear
relaxed and the
level of anxiety will
reduced to a
manageable level


-Monitor vital signs(e.g.,
rapid or irregular pulse,
rapid breathing)


-Use presence, touch,
verbalization or
demeanour to remind
client and to encourage
expressions or
clarification of needs,
concerns, unknowns
’and questions

- Accept client’s
defences, do not
confront, and argue and
debate

-Allow and reinforce
clients personal reaction
towards the threatens to
wellbeing

-Explain everything
necessary regarding the
disease


-To identify physical
responses associated
with both medical and
emotional conditions

-Being supportive and
approachable
encourages
communication





-If defenses are not
threatened, the client
may feel safe enough
to look at the behavior

-Talking or otherwise
expressing feeling
reduces anxiety


-To educate the patient
regarding the disease
to reduce anxiety


After 8 hours of
nursing
interventions
the patient
appeared
relaxed and the
level of anxiety
will reduced to
a manageable
level

2. June 23,2014
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


SUBJECTIVE:
“ m e d y o
m a s a k i t
yung
t i a y a n ko"
as verbalized by the
patient

OBJECTIVES:
-Vital signs,
BP130/90
Temp.36.2c
CR- 64
RR-20
-pain scale: 6/ 10
- -difficulty in
sleeping











Acute pain related to
irritation of the
mucosa and muscle
spasms.


Within 8 hours of
nursing
interventions the
Client expresses
pain diminished or
disappeared.




Encourage clients to
avoid foods / drinks that
irritate the gastric
mucosa: caffeine and
alcohol.

Encourage clients to use
the meals and snacks at
regular intervals




-Instruct patient to stop
smoking


Give drug therapy
according to the
program
Instruct to avoid drugs
are sold freely,
especially those
containing salicylates.



-to stimulate the
secretion of
hydrochloric acid.



-Schedule regular
eating helps retain
food particles in the
stomach that helps
neutralize the acidity
of gastric secretions.

-Smoking can
stimulate ulcer
recurrence.

Medicines containing
salicylates may irritate
the gastric mucosa.


After 8 hours of
nursing
interventions
the Client
expressed pain
diminished or
disappeared.

3. June 22, 2014
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


SUBJECTIVE:
"ano bang mga
dapat kong gawin
para maiwasan na
yung pag sakit ng
tiyan ko?" as
verbalized by the
patient

OBJECTIVES:
-sighing
-restlessness











Knowledge Deficit:
the prevention and
treatment of
symptoms related to
the condition of
inadequate
information.




Within 8 hours of
nursing
interventions
Clients gain
knowledge about
prevention and
management.





Assess the level of
knowledge and
readiness to learn from
clients.



Teach the required
information: Use words
that correspond with the
level of knowledge of
the client. Choose a time
when most convenient
and interested clients.
Limit counselling
sessions to 30 minutes
or less.

Assure the client that the
disease can be
overcome.






- Desire to learn
depends on the
physical condition of
the client, the level of
anxiety and mental
readiness

-Individualization
counseling improve
learning.








-Gives confidence can
have a positive
influence on behavior
change.



Within 8 hours
of nursing
interventions
Clients gained
knowledge
about
prevention and
management

4. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


SUBJECTIVE:
"hindi ko alam
kung
makakapagtrabaho
na ako kaagad
pagkagaling ko eh"
as verbalized by the
patient

OBJECTIVES:
-Vital signs,
BP130/90
Temp.36.2c
CR- 64
RR-20
-restlessness
-difficulty in
sleeping
-fatigue









Anxiety related to
threat to/ or change in
health status


Within 8 hours of
nursing
interventions the
patient will appear
relaxed and the
level of anxiety will
reduced to a
manageable level


-Monitor vital signs(e.g.,
rapid or irregular pulse,
rapid breathing)


-Use presence, touch,
verbalization or
demeanour to remind
client and to encourage
expressions or
clarification of needs,
concerns, unknowns
’and questions

- Accept client’s
defences, do not
confront, and argue and
debate

-Allow and reinforce
clients personal reaction
towards the threatens to
wellbeing

-Explain everything
necessary regarding the
disease


-To identify physical
responses associated
with both medical and
emotional conditions

-Being supportive and
approachable
encourages
communication





-If defenses are not
threatened, the client
may feel safe enough
to look at the behavior

-Talking or otherwise
expressing feeling
reduces anxiety


-To educate the patient
regarding the disease
to reduce anxiety


After 8 hours of
nursing
interventions
the patient
appeared
relaxed and the
level of anxiety
will reduced to
a manageable
level

5. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


SUBJECTIVE:
"mas madalas na
ko kumain ngayon
kaysa dati kasi pag
sumasakit na yung
tiyan ko, ikakain ko
lang para mawala."
as verbalized by the
patient

OBJECTIVES:
- Wt: 61 kg (may
29,)
Wt: 63 kg (june 27)







Imbalanced Nutrition
more than body
requirements related
to changes in diet


Within 8 hours of
nursing
interventions the
patient will
Identifies eating
habits that
contribute to weight
gain.

Determine current
eating patterns by
having keep a
Diary of what, when,
and where she eats.


Determine current
eating patterns by
having keep a
Diary of what, when,
and where she eats.




Within 8 hours
of nursing
interventions
the patient will
Identifies eating
habits that
Contribute to
weight gain.