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ASSESSMENT S: nanghihina ako as verbalized by the patient O: -poor muscle tone -less than 20% the ideal weight for his age -

NURSING DIAGNOSIS Imbalanced nutrition less than body requirements related to inadequate food intake

PLANNING After 30 minutes of nursing interventions the client will be able to: a.Verbalize understanding on the importance of proper diet .b.Enumerate foods to be included in his diet.

INTERVENTION Motivate the importance of nutrition

RATIONALE Eating habits are influenced by a person's tastes, habits, religion, economics and knowledge about the importance of nutrition for the body. Bowel sounds are decreased or increased indicates a disturbance in digestive function. Bad breath odor can reduce appetite. Presenting interesting food can increase appetite. food in small portions do not need energy, lots of easy distraction reflex.

EVALUATION At the end of the nursing interventions, the client was able to understand the importance of proper diet.

Auscultation bowel sounds

Perform oral hygiene every day. Serve food as attractive as possible Give small amounts of food often. Collaboration with a team of nutrition, the provision of a diet high in calories and high in protein.

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Assessment Subjective: Palagi lang akong nakahiga kasi hindi naman ako masyadong makagalaw, as verbalized by the patient Objective: -patient is physically immobile and unable to get out of bed. -the patient is using diaper and frequently wet. -weakness felt on the lower extremities -with limited range of motion -with stationary position of the legs

Diagnosis Risk for Impaired Skin Integrity related to Immobility secondary to Spinal injury

Planning After 1 hour of nursing Intervention the patient will be able to demonstrate ways to maintain good skin integrity

Intervention -Assist patient to change position once about every 2 hours.

Rationale -Positioning interventions reduce pressure and shearing force to the skin -To prevent skin irritation

Evaluation After 1 hour of nursing Intervention the patient was able to demonstrate ways to maintain good skin integrity

-Provide a firm, wrinkled free mattress -Provide perineal care and maintain the skin dry and clean -Massage bony prominences if not contraindicated -Educate patient on the importance of proper dieting and food intake.

-To prevent skin breakdown and bed sore -To enhance blood circulation

-Nutrition is fundamental to normal cellular -Monitor skin condition integrity and tissue at least once a day for repair. color or texture changes, Systematic dermatological inspection can conditions, or lesions identify impending problems early42

ASSESSMENT Subjective: nahihiya ako sa itsura ko as verbalized by the patient Objective: - patient has been bedridden ever since he was hospitalized - change in the shape of the back - gibbus formation

DIAGNOSIS Disturbed body image related to injury progressive destruction of the vertebral column secondary to Potts disease

PLANNING Within the shift the patient will be able to verbalize acceptance in selfsituation: - the patient will able to be free from any disturbance regarding the disease and will be able to gain self esteem

INTERVENTION establish therapeutic relationships conveying an attitude of caring and developing a sense of trust evaluate level of client6s knowledge and observe emotional changes identify previously used coping strategies and its effectiveness provide assistance with self-care needs note signs of grieving or indications of depression refer to appropriate support groups

RATIONALE to assist client to deal with or accept issues of self-concept related to body image to asses causative or contributing factors

EVALUATION Within the shift the patient was able to verbalized acceptance in selfsituation:

to determine skills and capabilities

to enhance capabilities to evaluate needs for counseling and medication to provide continuity of care

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