Nursing Prolems

8/13/2019 Nursing Prolems

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NURSING

PROLEMS

DATE: DAY:

July 20, 2013 Thursday

DATE: DAY:

June 21, 2013 Friday

Cues Intervention Evaluation Cues Intervention Evaluation

1. Disturbed

thought

process r/t

manic-

depressive

disorder

S: ako si Richard

gomez, dato raba

kaayo ko.

Kahbaw baka

maam na lami

e.loloO: inappropriate

based thinking;

flight of ideas

- introduce self to client

and established rapport

- assess clients

behavior, attitude,

problems and needs

- assess attention span/distractability and ability

to make decision or

problem-solving

- encourage client to

express feeling and

thoughts

-reorient to time/ place/

person/ self as needed

: ako si Richard

omez, dato

aayo ko. Artista

o sauna,

irector, actor

: flight of ideas,asy

istractability

-reorient to time/place/ person/ self as

needed


express feeling and

thoughts-maintain a pleasant,quiet environment and

approach in a calm

manner

-used positive regard,active listening and

provided safety to the

client

-presenting reality,stating what is real and

what is not without

arguing with the client

NURSING

PROLEMS

DATE: DAY:


DATE: DAY:

July 1, 2013 Monday


2. Defensive

coping r/t

inadequate

social

support

S: naa koy1

million, ayy

billion d.i to, naa

sa bangko,

hinatag sa ako

mama og papa

O: no eye-to-eye

contact,

pressured speech

andperseveration

noted, seductive

behavior

- call client by name,

ascertain how client

prefers to be addressed

- determine coping

mechanism used and

purpose of coping

strategy

- as much as possible,

ignore/withdraw your

attention from bizarreappearance and

behavior and sexual

acting-out

- note expression of

grandiosity

S:artista ko,

director ko,

producer ko,

dato ko, mao

nang ayaw ko

ninyo daog2x.a

O: pressured

speech and

perseveration

noted, seductivebehavior

- convey attitudes of

acceptance and

respect(unconditional

positive regard)

- explain instruction or

events in a simple,

concise manner

-use confrontation

judiciously

The nurse must keep allcommunications open,

regardless of speech

pattern

-encourage to express

feelings

NURSING

PROLEMS

DATE: DAY:

July 1, 2013 Monday

Cues Intervention Evaluation

3. Imbalanced

nutrition: less

than bodyrequirement r/t

inability to sit in

a long period

S: verbalized lack of appetite

O: pale mucous membrane note;

poor skin turgor more than 2seconds; loss of weight with

adequate food intake

- determine ability to chew, swallow, and taste

- provide client with high protein, high caloric,

nutritious finger foods and drinks that can beconsumed on the run

- encourage client to eat what is served

- prevent/minimize unpleasant odors or sight

- pace or walk with client as finger foods are

taken. as agitation subsides, sit with client

during meals

-explain the importance of adequate nutrition

and fluid intake


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NURSING

PROLEMS

DATE: DAY:

July 2, 2013 Tuesday

DATE: DAY:

July 15,2013 Monday


4. Risk for

other-

directed

violence r/t

perceptional

distortionsecondary to

manic

episodes

S: pepito imo

pangan, wa pa

raba ko kapatay

og pepito

O: aggressive

behavior noted,hyperactivity

noted and

restlessness,

agitation noted,

hostile attitude

observed

- provide a safe

environment

- removed all dangerous

objects from clients

environment

- set and maintain limitson behavior that is

destructive or adversely

affects others


verbalize feelings

-redirect the violent

behavior with physical

outlets

-approach client in a

calm manner

S: ayaw ko ninyo

cege pakan.a og

igit ha! Mga buang

mo! Tarung raba

ko. Kaning mga

nurse, doctor, mgamatay mug una ,

ako kai d ko

mamatay, mga

matay mu tanang

O: aggressive

behavior noted

before going to

sleep, hostile

attitude noted

- removed all

dangerous objects

from clients

environment

- decreased

environmental stimuliwhenever possible

-redirect the violent

behavior with physical

outlets

-maintain and convey a

calm attitude to the

client

- give simple direct

explanation do not

argue with the client.

NURSINGPROLEMS

DATE: DAY:

July 3, 2013 Wednesday


5. Impaired

Social

Interaction

r/t

grandiosity

secondary to

disturb

thought

process

S:d ko ganahan makig sturya ana nla kay

awayon ta og yoyo kabayo sakit kaayo

O: sleepiness noted, seldom talks to

others as observed, hallucination noted,

fight of ideas, grandiosity noted,

-work with the client to alleviate underlying

self-concepts

- set limits to manipulative behaviours.

Explain to client what you expect and what

the consequences are if the limits are

violated

- help client identify positive aspect about

self

-encourage client to converse with others

- provide positive reinforcement. Explore

feelings, and help client seek more

appropriate ways of dealing with them

NURSING

PROLEMS

DATE: DAY:


DATE: DAY:

July 1, 2013 Monday


6. Disturbed

sensory

perception

r/t altered

sensory

perception

S: none

O: delusions

observed, rapid

mood swings,

exaggerated

emotional

responses,

disoriented totime and place,

restlessness and

irritability noted,

and excessive

crying noted

- assess ability to speak and

respond to simple

commands

- observe for behavioral

responses e.g.,

illusions/hallucinations,

delusion, hostility, excessive

crying, etc.- provide a stable

environment with continuity

of care by same personnel as

much as possible.

- avoid isolation of client,

physically or psychologically

- minimize discussion of

negative feedback within

clients hearing

S: gibyaan kos

akong mama og

papa, pero mahal

ghapon nako kaayo

sila(pt. then cries)

O: : delusions

observed, rapid

mood swings,exaggerated

emotional

responses,

disoriented to time

and place,

restlessness and

irritability noted,

and excessive

crying noted

-provide safety

measure

-reorient to time,

place, and persons,

-- provide a stable

environment with

continuity of care

by same personnelas much as possible.

- avoid isolation of

client, physically or

psychologically

- minimize

discussion of

negative feedback

within clients

hearing


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NURSING

PROLEMS

DATE: DAY:

July 3, 2013 Wednesday


7. Chronic low

self-esteem r/t

S:d ko ganahan makig sturya ana nla

kay awayon ta og yoyo kabayo sakit

kaayo

O: lack of eye to eye contact,sleepiness noted, seldom talks to

others as observed, hallucination

noted, fight of ideas, grandiosity

noted,

-emphasize need to avoid comparing self with

others.

- convey attitudes of acceptance and

respect(unconditional positive regard)- explain instruction or events in a simple,

concise manner

-use confrontation judiciously

The nurse must keep all communications open,

regardless of speech pattern

-encourage to express feelings

- involve client in activities, to promote

socialization.

NURSING

PROLEMS

DATE: DAY:

July 2, 2013 Tuesday

Cues Intervention Evaluation8. Disturbed

energy field r/t

S: pepito imo pangan, wa pa raba ko

kapatay og pepito

O: aggressive behavior noted,

hyperactivity noted and restlessness,

agitation noted, hostile attitude

observed

- provide a safe environment

- shorten interaction or treatment as much as

possible

- provide client a long period of rest after

procedures.

- removed all dangerous objects from clients

environment

- set and maintain limits on behavior that is

destructive or adversely affects others

- encourage client to verbalize feelings

-redirect the violent behavior with physical

outlets

-approach client in a calm manner

- removed all dangerous objects from clients

environment

NURSING

PROLEMS

DATE: DAY: DATE: DAY:


9. Self-care

deficit r/t

cognitive

impairment

S:

Documents

Nursing Prolems