ASSESSMENT S: no subjective complaint O: Incomplete emptying of the bladder Difficulty in urinating Distended bladder

NURSING DIAGNOSIS Risk for urinary incontinence related to decreased bladder capacity secondary to effects of alcohol

PLANNING At the end of the nursing interventions the patient will identify behaviours and lifestyle changes to prevent development of the problem

INTERVENTIONS Measure amount of urine voided

Regulate fluid intake Provide assistance or devices for clients who are mobility impaired Encourage to avoid intake of alcohol even coffee or tea Offer bed pan or urinal in patients who cannot go to the comfort room Encourage to wear loose fitting clothes Emphasize importance of perineal care after each voiding

RATIONALE To determine bladder capacity and effectiveness of bladder contraction to facilitate emptying To promote predictable voiding pattern To easily allow the patient to void

EVALUATION Goal met Patient understand the ways on how to prevent development of the problem

It has irritating effects on the bladder To facilitate voiding

To facilitate response to voiding urge To reduce risk of ascending infection and for the patients comfort

ASSESSMENT S: no subjective complaint O: Difficulty of breathing Nasal flaring Use of accessory muscles while breathing Increased respiration rate

NURSING DIAGNOSIS Ineffective breathing pattern related to neuromuscular dysfunction

PLANNING At the end of the nursing interventions the patients will establish a normal breathing pattern

INTERVENTIONS Auscultate chest

Administer oxygen at the lowest concentration indicated Elevate head of the bed Encourage use of relaxation techniques Encourage position of comfort. Reposition the client if immobility is the factor Maintain calm attitude while dealing with the client significant others Stress the importance of good posture Encourage adequate rest period Encourage to avoid alcohol and smoking

RATIONALE To evaluate the characteristics of breath sounds For management of underlying pulmonary condition or respiratory distress For maximal lung expansion To provide comfort

EVALUATION Goal partially met Patients still some time of difficulty in breathing

To provide comfort and avoid skin integrity To limit level of anxiety

To maximize respiratory effort To limit fatigue To prevent predisposing factors of the disease

Assessment Subjective: Namamanhid ang mga binti at hita ko as verbalized by the patient Objective: >with tingling on both upper and lower extremities >with muscle weakness >weak in appearance >unable to move feet > limited range of motion

Diagnosis Impaired physical mobility related to decrease muscle strength

Planning At the end of nursing interventions patient will increase muscle strength and function

Intervention >note emotional responses >observe movement when client is unaware of observation

Rationale -feelings of frustration may impede attainment of goals -to note any incongruencies with reports of abilities -for position changes or transfer

Evaluation Patient able to increase muscle strength and function as evidenced by >able to move upper and lower extremities in a slow manner >able to perform basic activities

> instruct in use of side rails for position changes

>support affected body parts

-to maintain position and function and reduce risk of pressure ulcer -enhance self-concept and sense of independence -limits fatigue and maximize participation

> encourage participation in self-care

>identify energy conserving for ADL >Provide comfort measures >encourage adequate intake of fluids and nutritious foods >encourage significant others involvement in decision-making >review safety measures as

-promote well-being and maximizes energy production -enhances commitment to plan

individually indicated

Assessment Subjective: Nahihilo talaga ako ngayon as verbalized by the paitent Objective: >with dizziness >with headache >pale in appearance >with dry lips >BP of 90/60mmHg >with generalized weakness noted

Diagnosis Risk for injury related to generalized weakness as evidenced by verbal report of dizziness

Planning At the end of nursing intervention, patient demonstrate factors that contribute to possibility 0f injury

Intervention >ascertain knowledge of safety needs

Rationale -to prevent injury in home, community and work setting -Increase risk taking without consideration of consequences -to identify risk for falls

Evaluation Patient demonstrated the factors that contribute to possibility 0f injury as evidenced by >patient has @ least 1 SO >side rails secured >devices that may cause injury removed

>assess mood, coping abilities, personality styles >assess clients muscle strength, gross and fine motor coordination

>monitor environment potentially unsafe conditions

-to promote safe physical environment and individual safety

>remove devices that may cause injury >secure side rails >instruct SO not to leave the patient alon