ASSESSMENT/ CUES

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOME

S- O O- the patient manifested the following: Dirty fingernails Dry hair With presence of untidy hair With body weakness Needs assistance when doing a procedure such as dressing

Self-care deficit related to body weakness

Short-term: After 5 hrs of NI, the patient will verbalize the understanding of the importance of proper hygiene Long-term: After 5 days of NI, the patient will demonstrate behavior and lifestyle changes

Establish

rapport Assess general condition

To gain

Monitor and
record VS

Encourage

proper wound care

trust To obtain baseline data To achieve baseline data To prevent spread of infection

Short-term: The patient shall verbalize the understanding of the importance of proper hygiene Long-term: The patient shall demonstrate behavior and lifestyle changes

Encourage

To prevent
cross infection

proper hand washing

Encourage to
increase OFI

To keep

rehydrated

Encourage to
reposition q 2 hrs

To prevent
bed sores

The patient may manifest the following: Foul odor Infection on wound site

Encourage to
do sponge bath

To

promote hygiene even if theres

 Provide

health teaching regarding good oral hygiene Instruct SO to assist patient in performing the procedure Provide privacy while performing hygiene care

body weakness To provide adequate knowledge on oral hygiene

To avoid

accident

To

Provide

comfort measure

promote privacy and comfort To provide comfort

Provide

adequate rest periods

To

Provide safety
measures

Give due

medications

decrease oxygen demand To promote safety To treat underlying conditions