ncp for cip

8/3/2019 NCP FOR CIP

1/22

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

di na komasyadongmakatulong

dito sa bahaykasi mabilisakongmapagod

Objectives:

- W eak inappearance

- BP 150/90

Activityintolerancerelated tobodyweaknesssecondary tounderlyingdiseaseprocess

Diseaseprocess

Body needsincreasedeffort forsystemic

circulation

Increasedenergy used

in response tothe increased

workloadneeded

Lack ofenergy for

otherphysical

activities

Short Term:

After 2-3hours ofnursing

interventionthe patientwill identifynegativefactorsaffectingactivityintoleranceand how toreduce theireffects when

possible

Long Term:

The patient

will useidentifiedtechniques toenhance

Independent:

y Ascertainability tostand andmove aboutand degree ofassistancenecessary

y Identify and

prioritizeactivitiesneeded

y Reduceintensity level

or encourageto discontinueactivities thatcauseundesiredphysiologicalchanges

y Todeterminecurrentstatus andneedsassociatedwith desiredactivities

y To conserve

energy andavoid fatigue

y To preventoverexertion

After 3 hoursof nursinginterventionsthe patientidentifiednegativefactorsaffectingactivityintolerance

and how toreduce theireffects.


2/22

ActivityIntolerance

activitytolerance

y Increaseactivity/exercisegradually

y Teachmethods toconserve

energy

y Balance restperiods withactivities

y Provide brief

informationabout thepatientscurrentcondition andhow to avoid

exacerbatingor worseningthe condition

y To preventy y overexertion

y To assistclient to dealwithcontributingfactors

y To preventfatigue

y To provideknowledgeto patientandencourageto avoid

sedentarylifestylethat willworsen hiscondition


3/22

ASSESSMENT NURSINGDIAGNOSIS

INFERENCE PLANNING NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective:

Para saan ba yung gamot ko?!

Objective:

-misunderstandingof the cause andtreatment of thedisease

-confused

-denial

Knowledgedeficit r/t

chronic diseasemanagement

Inheriteddisease

Age

Prolonged H PN

Unhealthylifestyle

lack ofinformationabout thedisease

Knowledgedeficit r/t

chronic diseasemanagement

After 30 minsof nursing care,the patient willverbalizeunderstandingof the disease

and themanagementthat can bedone.

Monitor clientsvital signs,especially BP

Define andstate the unitsof desired BP

Assist thepatient inidentifyingmodifiable riskfactors like diet

R einforce theimportance oftreatmentregimen andkeeping follow up

appointments

Encouragepatient todecrease oreliminate

caffeine like tea,coffee, cola and

For baselineparameter

Provides basisforunderstandingelevations of BP

This may havebeen shown tocontribute tohypertension

To avoidfailure ofcompliance tohisantihypertensivetherapy

Caffeine is acardiacstimulant andmay adverselyaffect cardiac

function

After 30 minsof nursing care,the patientverbalizedunderstandingof the disease

and themanagement tobe done.


4/22

chocolates

Stressimportance ofaccomplishingdaily rest periods

Provideinformationregardingcommunityresources andsupport programsin makinglifestyle changes

Instruct thepatient or thesignificantothers on how totake bloodpressure

Tell the patientand family tokeep a record ofdrugs used in thepast

Suggest

To promoteadequate rest

Communityresources likehealth center

programs andcheck ups arehelpful inmonitoring BP

To monitorclients BP

To determineand evaluate themedicationbeing used

To have a


5/22


6/22


INFERENCE PLANNING NURSINGINTERVENTIONS


Subjective:Hindi komapigilan angpaninigarilyoko.

Objective:

(+) Smoker (+) alcoholdrinker

B .P.: 150/90

IneffectiveHealth

Maintenancerelated to

Inability tomodify

lifestyle

Patient wassmoking sincehe was 17yrs.

Old

Patient ishypertensive

Patient wasntable to stopsmoking and

drinkingalcoholic

beverages.

Inability tomodify

lifestyle

After 2 hoursof nursinginterventionsthe patientwill learn andverbalizeunderstandingof factors

contributingto currentsituation.

Identify andteach the client ofthe factors thatcontributes tohypertension.

Evaluate clientfor substance use.

N ote settingwhere the clientlives.

Assess clientsdesire to learnabout his health.

Help the client tochoose a healthylifestyle.

This can helpthe client tolearn moreabout whatcauseshypertension.

Affectsclients

desire/abilityto help self. To note

individualadaptationneeds.

To know ifthe client iseager to helphimself.

Healthylifestylemeasures,

such asexercisingregularly,maintaining ahealthyweight, notsmoking, andlimiting alcoholintake, help

After 2 hoursof nursinginterventionsthe patientlearned andverbalizesunderstandingof factors

contributingto currentsituation.


7/22

Discuss with

client realisticgoals for changesin healthmaintenance.

reduce therisk of beinghypertensiveand otherdiseases.


8/22




Subjective:Madalas akongmahilo,asverbalized bythe patient.

Objectives:

(+) dizziness

(+) headache

B .P.: 150/90

DecreasedCardiacOutput

related toincreasedvascular

resistanceSecondary to

Hypertension

Hypertension

Decreasecircumference of

the arteriallumen

Increasesystemicvascular

resistance

R educed abilityof the heart to

pump effectively

Inadequate blood

pumped by theheart to meetthe metabolic

demands of thebody

DecreasedCardiac Output

Short-term:

After 6 hrsof nursinginterventions,the client will haveno elevation inblood pressure

above normallimits and willmaintainblood pressurewithinacceptable limits

Long-term:

After 5 daysof nursinginterventions,the client will

maintainadequate cardiacoutput.

Independent:

y Evaluatequality andequality ofpulses, asindicated.

y Auscultateheart soundsfor presenceof murmurs.

y Monitorheart rateand rhythm.

y N oteresponse toactivity andpromote restperiodappropriately

-Decreasedcardiac outputresults indiminishedweak/threadpulses which

suggestdysrhytmias.-To indicatedisturbancesof normalblood flowwithin theheart.-Heart rateand rhythmrespond tomedication,activity and

developingcomplications.-Overexertionincreasesoxygenconsumption/demand and cancompromisemyocardial

Short-term:

After 6 hrsof nursinginterventions,the client will haveno elevation inblood pressure

above normallimits and willmaintainblood pressurewithinacceptable limits

Long-term:

After 5 daysof nursinginterventions,the client

maintainedadequate cardiacoutput asevidenced byabsence of signsand symptoms.


9/22

Dependent:

y Administersupplementaloxygen asindicated.

Collaborative:y Review serial

ECGs

y Monitorlaboratorydata (cardiacenzymes,ABgs,electrolytes)

function.

To increaseamount ofoxygenavailable formyocardialuptake,reducingischemia.

To provideinformationregarding.progression/resolutionofinfarction,status ofventricularfunction andeffects ofdrug

therapies.To identifycausative/contributingfactors


10/22

y Refer to

nutritionistto providesmall/easilydigestedmeals. LimitcaffeineIntake(coffee,

chocolate,cola, asindicated)

Large mealsmay increasemyocardialworkload.Caffeine isdirectcardiacstimulantthat can

increaseheart rate.


11/22




Subjective:

N ag-aalala akopag iniisip koang sakit ko.As verbalizedby the patient.

Objective:

y R estlessy Irritabley BP : 150/90

Mild anxietyrelated to

presentcondition

Diseaseprocess

Increasestress

perception

Unfamiliarcondition

about patients

health

Perceivedthreat to

health

R esulting tomild anxiety

After 1 hour ofnursing healtheducation/teachingto the patient andfamily members/significant others,

the client willdiminish and willbe relieve fromanxiety

-identify patientsperception of the

threatrepresented by

the situation

-Determine

current prescribedmedications and

recent drughistory of

prescribed or OTCmedications

-monitor physicalresponses: VS,

palpitations, rapidpulse, repetitive

movements, pacing.

-be aware ofdefense

-to assesslevel ofanxiety

-These

medicationscan heightenfeelings/sense

of anxiety

-to identifyphysical

responsesassociated

with bothmedical andemotionalconditions.

-that

-after nursinghealth

teaching thepatient

understandsthe purpose of

the educationand willing todo the

interventions.


12/22

mechanism beingused. may be

denial, regression

and so forth andencourage patientto acknowledgeand to express

feelings.

-provide accurateinformation aboutthe situation. Helppatient to identify

what is realitybased.

-be available topatient for

listening andtalking.

-reviewhappenings,

thoughts andfeelings precedingthe anxiety attack.

interfere withability to dealwith problem.

-to build

rapport andtrust.

-to helppatient relieve

anxiety

-to helppatient relieve

anxiety


13/22




Subjective: -

Objective:

-weight: 51kg

-BMI: 17.6(underweight)

Normal: 20-25

-(+) fatigue

-(+) dizziness

Imbalance

nutrition:less thanbody

requirementsr/t lack ofinformation

Lack of

information

Unhealthylifestyle

Lack ofknowledge of

eatinghealthyfoods

Imbalancenutrition:less than

bodyrequirements

After 1 hour

of nursingintervention,the clientandsignificantothers willable todemonstratebehaviors,lifestylechanges toregainand/or

maintainappropriateweight

y Ascertain

understandingof individualnutritionalneeds

y N oteavailability/use offinancialresources andsupportsystems

y Asses weight;measure/calculate body fatand musclemass viatriceps skin

fold andmidarm musclecircumferenceor otheranthropo-metricmeasurements

To determine

information needs ofclient/SO

To establish baselineparameters

After 1 hour

of nursingintervention,the client andsignificantothers wasable todemonstratebehaviors,lifestylechanges toregain and/ormaintainappropriate

weight


14/22

y N ote age,body

build,strength,activity/restlevel, etc.

y Use flavoringagents

y R efer to homehealthresources

Helps determinenutritional needs

To enhance foodsatisfaction andstimulate appetite

Forinitiation/supervisionof home nutritiontherapy when used


15/22

Health Problem Family Nursing

Problem

Goal of Care Objectives of

Care

Intervention PlanNursing

Interventions

Method of

Nurse-FamilyContact

Resources

Required

N oncomplianceto medicationregimen as a

health deficit

Inability toprovide

sufficientsupply for the

medication.

Insufficientmoney to

sustain theneed for drugmaintenance.

After nursingintervention thepatient and thefamily will takethe necessary

measures tomanage andcontrol the

propercompliance to

the medication.

After nursingintervention thefamily will:

have adequateknowledge or

ideas on howthey will beable to findsource ofincome.

be able todetermine the

risk ofnoncomplianceto medication.

be able tocomply for themedicationregimen.

Discuss thenature, signs,symptoms andcomplicationsthat might

arise due tononcomplianceto themedication.

Provideinformation andhelp the family

to know whereand how to findsource ofincome.

Encourage thefamily to joincommunity

activities orprograms thatwill help provideextra income.Provide

sufficientfinancial

support for themedication.

Home Visit Humanresources:

Time and efforton the part of

the studentnurse and

family

Financialresources:

Money for thestudent nursetransportation


16/22

Provideknowledgeabout thebenefits of

complying themedication andits risks if not.


17/22


Problem

Goal of Care Objectives of

Care


Interventions

Method of

Nurse-FamilyContact

Resources

Required

N oncomplianceto medicationregimen as a

health deficit

Inability toprovide

sufficientsupply for the

medication.

Insufficientmoney to

sustain theneed for drugmaintenance.

After nursingintervention thepatient and thefamily will takethe necessary

measures tomanage andcontrol the

propercompliance to

the medication.


have adequateknowledge or

ideas on howthey will beable to findsource ofincome.

be able todetermine the

risk ofnoncomplianceto medication.

be able tocomply for themedicationregimen.

Discuss thenature, signs,symptoms andcomplicationsthat might

arise due tononcomplianceto themedication.

Provideinformation andhelp the family

to know whereand how to findsource ofincome.

Encourage thefamily to joincommunity

activities orprograms thatwill help provideextra income.Provide

sufficientfinancial

support for themedication.


Time and efforton the part of

the studentnurse and

family

Financialresources:

Money for thestudent nursetransportation


18/22

Provideknowledgeabout thebenefits of

complying themedication andits risks if not.


19/22


ProblemGoal of Care Objectives of

Care


InterventionsMethod of

Nurse-FamilyContact

ResourcesRequired

Hypertension Inability tomake decisionswith respect to

takingappropriate

health actionsdue to lack of

adequateknowledge inthe nature of

the healthproblem.

After nursingintervention thefamily will takethe necessarymeasures to

properlymanage, control

and lessen therisk factors ofhypertension.


have adequateknowledgeabout propernutrition that

will help reducehypertension.

be able todetermine therisk factorsthat contributeto hypertension

practiceproper lifestylewith regards tonutrition andphysical fitness.

Discuss thenature, signs,symptoms andcomplicationsthat mightarise due tohypertension.

Discuss withthe family therisk factors ofhypertensionsuch as familyhistory, age,salt and alcohol

intake andobesity.

Promote ahealthylifestyle suchas encouragingproper food

intake likereduced saltand fattyfoods.

Imply theimportance ofhaving an

exercise. Discuss ways

Home Visit Time andeffort on thepart of thestudent nurseand family


20/22

in Smokingcessation.

Deliberatethat tobacco or

nicotinepromotesatherosclerosisthat maycontribute tohypertension.

Encourage

check-ups andprovidereferral with amedicalpractitioner tolessenhypertension

and modifyrisk-factors.


21/22

Health Problem Family Nursing Problem Goal of Care Objectives of

Care


InterventionsMethod of

Nurse-FamilyContact

ResourcesRequired

Hypertension asa health threatto the rest of

the family

1. Inability tomanagedhypertension dueto lack ofknowledge aboutthe condition.

2. Inability to make

decisions withrespect to takingappropriate healthaction on thehealth threat dueto failure tocomprehend to the

nature of theproblem.

3. Inability toprovide a homeenviron-mentconducive tohealth

maintenance dueto:a. Ignorance of

preventivemeasures

b. Inadequatefamily

resourcesspecifically

After nursingintervention, the

possibility ofuncontrolled

hypertension willbe minimized or

prevented.


Correct wrongnotions aboutthe cause ofhypertension.

R ecognizebeginning casesof hypertensionand applypreventive/therapeuticmeasures.

Discuss thenature, signs,symptoms andcomplications ofhypertension ifpropermanagement is

not done.Explore with

the family waysof implementingmeasures tomaintain propermanagement

and preventionofhypertension.


Time and efforton the part ofthe studentnurse and

family

Financialresources:

Money for thestudent nurse

transportation


22/22

financialrsources

ncp for cip

Documents