B.

NCP with Evaluation

CUES NURSING ANALYSIS NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTION

S: “mga march 30 P> Impaired Surgical procedure to 04-11-07 6am Independent: Date: 04-12-07
noong physical mobility remove tumour With in the 2 day Encourage and facilitate Proper circulation and Time: 2:00pm
↓ stay patient will
magsimulang di Re occurrence of tumour perform physical
early ambulation and other promotion of proper hygiene Level of Attainment:
niya maigalaw ang E>r/t on left area of the frontal activity e.g. ADL when possible e.g. -goal met
kanyang kanang neuromuscular lobe PROM, patient is taking daily bath  AEB: pt performs
bahagi ng kanayang impairment, ↓ free of PROM exercises.
katawan niya” as affectation of the complication of Allow patient to perform Increases pt self esteem.
CNS affectation immobility AEB
 Normal vowel
verbalized by the CNS ↓ intact skin,
task @ his own rate. movement.
mother. Motor paralysis of the absence of  No pressure sores any
“ lagi siyang S> AEB “mga lower extremities and r thrombophlebitis Keep side rails of bed & Promotes safe environment. complication of
irritable mula march 30 noong arm and normal strap of chair put on. immobility.
noong naoperahan magsimulang di ↓ vowel movement
Weakness on affected
siya sa ulo” as niya maigalaw extremities.
Monitor I & O, nutritional Pressure sores develop more
verbalized by the ang kanyang ↓ status. quickly in pt. w/ a nutritional
mother. kanang bahagi ng Impaired physical deficit
“ako nga lang ang kanayang mobility. Turn pt q 2hrs To optimize circulation to all
kinakausap niya ng katawan niya” as tissues & relieves pressure.
matino. Minsan verbalized by the Perform PROM exercises To promote venous return,
ayaw din niya mother. to all extremities. prevents stiffness and
akong kausapin” maintains muscle strength.
added by the Neuromuscular Encourage coughing and Prevent build up of secretion,
mother weakness on both DBE. development of hypostatic
O: lower extremities pneumonia.
 Conscious and and r arm. Encourage liquid intake To optimize hydration &
coherent. unless contraindicated. prevent hardening of stool
 Not in distress
 Weak in
appearance Collaborative:
 Muscle wasting Consult rehabilitation
on the r arm and personnel or therapist as
lower extremities appropriate.
noted.
 Irritable.
 Impaired speech,
only speaks 1 P>Self care Neuromuscular With in the Independent:
word at a time.\ deficit impairment course of stay Set short range goals with To facilitate learning and ↓
E>r/t secondary to PNET patient will pt. frustration Level of Attainment:
 V/S as follows:
neuromuscular ↓ perform -goal met
BT 36.8C
impairement @ r Inability to move safely self Use consistent routines This helps pt to organize and  AEB: pt able to do
PR: 100bpm
arm and lower lower extremities & r care activities carry out care activities. self care activities
RR: 18cpm
extremities. arm. with Provide pt appropriate These increases opportunities with the assistance of
c HL @ R forearm ↓
S>inability to assistance of utensils for success. the mother and the
intact Inability to perform
feed self others. student nurse
(-) DOB task of daily living
independently Provide assistance as Reduces energy expenditure
Hgb 146 such as bathing. needed during: and frustration at the same
Hct 44% ↓
Inability to dress >dressing/grooming. time promoting safety.
WBC 11.2 Self care deficit
Neutrophils 0.92 self >bathing
Lymphocytes 0.08 independently >ambulation
Platelet count: 295
Inability to bathe Collaborative:
& groom Provide assistive devices Makes task easier for patient.
independently. for ambulation assessed by
occupational therapist.
P>impaired social Tumor on the left Independent:
interaction frontal area of the After the shift Assess for the history of Provides a baseline and serves
E>r/t irritability, brain patient will the child. as guide in exhibiting the Level of Attainment:
complication of ↓ show social interaction. -goal partially met
the tumor. Surgical intervention interaction  AEB: pt is able to
S>“ lagi siyang to remove mass skills and Talk smoothly, with Establishes rapport and gains utter words clearly but
irritable mula ↓ appropriate positive regard an active the trust of the patient. sometimes he is still
noong Re-occurrence of the respond to the listening to the patient. irritable.
naoperahan siya tumor interaction
↓
 He is able to express
sa ulo” as being Encourage the patient to Helps the patient verbalized what he needs by
Destruction of neural
verbalized by the established. talk even single words at a his needs. making a cry.
tissues
mother. ↓
time.  Rarely speaks.
Affectation of speech  Patient is able to
“ako nga lang ang And irritability Coordinate with parent to Positive rewards gain the interact with other
kinakausap niya ↓ provide positive reward for compliance of the patient to people.
ng matino. Impaired social the compliance with the interactions.
Minsan ayaw din interaction. interaction.
niya akong
kausapin” added
by the mother.

Irritability.
Cannot or does
not speak.