19493715-Ncp-Tetanus

19493715-Ncp-Tetanus - NURSING LONGTERM SHORT CUES...

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CUES NURSING DIAGNOSIS LONGTERM GOAL SHORT TERM GOAL NURSING INTERVENTION RATIONALE EVALUATION S”Konti lang ang tulog niya mga 2 hours at paputol- putol.” verbalized by husband of the patient O: (+)Sunken eye balls (+) Weakness (+) Yawning (+) Fatigue appearance Disturbed sleep pattern r/t biochemical agents such as medicines After 5 days of nursing interventions the patient will be able to maintain and improve sleep pattern. After 4 hrs. Of nursing of intervention the patient relatives will be able to verbalize understandin g of necessary intervention to improve sleep pattern. >Monitored v/s >Assessed patient schedule of sleep. >Instructed patient relaxation techniques. >Instructed patient to limit fluid intake at night. >Instructed patient family to provide quite environment. To note changes and a serves as baseline data It may contribute in disturbing sleep pattern at night. To decrease tension, prepare for sleep. To reduce need for nighttime elimination. To reduce stimulation that the client may relax and fall asleep. LONGTERM GOAL: After 5 days of nursing, interventions the patient able to maintained and; improved sleep pattern as evidenced by 4-6 hours of sleep at night SHORTTERM GOAL: After 4 hours of nursing intervention the patient relatives was able to verbalized understanding of necessary intervention to improve sleep pattern.
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CUES NURSING DIAGNOSI S LONGTER M GOAL SHORTTERM GOAL NURSING INTERVENTION RATIONALE EVALUATION S:”di nga siya pwedeng tumayo sabi ni Dok” verbalized by the husband of the pt. O: (+) Leg muscle weakness >Inability to performed ADL >Reluctance to attempt movement > Limited range of motion >Doctors order of CBR. (+) Tracheostom
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19493715-Ncp-Tetanus - NURSING LONGTERM SHORT CUES...

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