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    NCP (Coa) Final Activity

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    Eunice Mañalac
    Provide ➔ To assess safety risks and prevent injury non-pharmacological ➔ Eliminate hazards and educate on safety measures interventions and ➔ Goal of safe independence met after nursing care patient education. ➔ Focused on visual impairment and home environment.

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    NCP (Coa) Final Activity

    Uploaded by

    Eunice Mañalac
    26 views7 pages
    Provide ➔ To assess safety risks and prevent injury non-pharmacological ➔ Eliminate hazards and educate on safety measures interventions and ➔ Goal of safe independence met after nursing care patient education. ➔ Focused on visual impairment and home environment.

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    Original Title

    NCP (COA) FINAL ACTIVITY

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    Provide ➔ To assess safety risks and prevent injury non-pharmacological ➔ Eliminate hazards and educate on safety measures interventions and ➔ Goal of safe independence met after nursing care patient education. ➔ Focused on visual impairment and home environment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    26 views7 pages

    NCP (Coa) Final Activity

    Uploaded by

    Eunice Mañalac
    Provide ➔ To assess safety risks and prevent injury non-pharmacological ➔ Eliminate hazards and educate on safety measures interventions and ➔ Goal of safe independence met after nursing care patient education. ➔ Focused on visual impairment and home environment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 7

    ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

    INTERVENTION

    Subjective Data: Acute pain r/t increased After 8 hours of nursing ➔ Note the ➔ To assess After 8 hours of nursing
    cerebral vascular intervention, the client’s etiology or intervention, the
    “Masakit ang batok ko at pressure. patient’s BP of attitude precipitating patient’s BP of
    nanghihina ako” as 190/160mmHg will toward pain contributory 190/160mmHg
    verbalized by the decrease to at least decreased to
    and use of factors.
    patient. 140/120mmHg. 130/100mmHg.
    pain
    Objective Data: medications, Goal met.
    BP: 190/160mmHg including any
    - Headache history of
    - Wrinkled brow substance
    - Restless abuse.
    - Dizziness ➔ Encourage and ➔ Minimizes
    - Nausea maintain bed stimulation
    rest during the and promotes
    acute phase. relaxation.
    ➔ Provide or ➔ Measures that
    recommend reduce
    nonpharmacol cerebral
    ogical vascular
    measures to pressure and
    relieve slow or block
    headache such sympathetic
    as cool cloth to response
    forehead; back effectively
    and neck rubs; relieve
    quiet, dimly lit headaches and
    room; associated
    relaxation complications.
    techniques
    (guided
    imagery,
    distraction);
    and
    diversional
    activities.
    ➔ Eliminate or
    minimize ➔ Activities that
    vasoconstricti increase
    ng activities vasoconstricti
    that may on accentuate
    aggravate the headache
    headaches. in the
    presence of
    increased
    cerebral
    vascular
    ➔ Assist patient pressure.
    with ➔ Dizziness and
    ambulation as blurred vision
    needed. frequently are
    associated
    with vascular
    headaches.
    The patient
    may also
    experience
    episodes of
    postural
    hypotension,
    causing
    weakness
    when
    ambulating.
    ➔ Note the
    patient’s ➔ History of
    attitude substance
    towards pain abuse can be a
    and any factor of
    history of having
    substance hypertension.
    abuse.

    DEPENDENT:
    ➔ Administer
    medications ➔ Reduce or
    as prescribed control pain
    by the and decrease
    physician. stimulation of
    the
    sympathetic
    nervous
    system. May
    aid in the
    reduction of
    tension and
    discomfort
    that is
    intensified by
    stress.
    ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
    INTERVENTION

    Subjective data: Risk for injury r/t After 12 hours of nursing ➔ Assess the ➔ This is to After 12 hours of nursing
    impaired visual acuity intervention, the patient general status determine the intervention, the patient
    will be free of injury and of the patient patient’s is free of injury and is
    will be able to perform condition that able to perform
    activities within may cause activities within
    parameters of sensory injury. parameters of sensory
    limitation. ➔ Determine ➔ Exposure to limitation.
    Objective data: whether community
    - GRADO NG MATA exposure to violence has Goal met.
    community been associated
    violence is with increases
    contributing to in aggressive
    risk for injury. behavior.

    ➔ Check on the ➔ Patients


    home experiencing
    environment for impaired visual
    threats to acuity are at
    safety. risk for injury
    from common
    hazards
    ➔ Eliminate or ➔ This is to
    drop all possible prevent the
    hazards in the patient from any
    room such as unpleasant
    razors, experience due
    medications, to dangerous
    and matches. objects.
    ➔ Validate the ➔ Validation lets
    patient’s the patient
    feelings and know that the
    concerns nurse has heard
    related to and
    environmental understands
    risks. what was said,
    and it promotes
    the nurse-
    patient
    relationship.
    ➔ Educate patient ➔ Patient’s
    about safety knowledge
    ambulation at about his or her
    home, including condition is vital
    the use of to safety and
    safety recovery.
    measures such
    as handrails in
    bathroom.

    ➔ For patients ➔ Lighting an


    with visual unfamiliar
    impairment, environment
    educate them or helps increase
    caregiver to visibility if the
    label with bright patient must get
    colors such as up at night.
    yellow or red
    significant
    places in
    environment
    that must be
    easily located
    (e.g., stair
    edges, stove
    controls, light
    switches).

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