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PRIORITIZED NURSING PROBLEMS

CUES Subjective: When the patient was asked if she feels any pain during positioning she verbalized, masakit or she moans. The grandson verbalized, nakabaluktot na talaga yung kamay at paa nya, hindi na naidederetso and hindi nya din talaga nagagalaw yung kaliwa nyang katawan. Objective: (+) body weakness (+) paralysis on left side of the body (+) right facial weakness Inability to perform motor skills: the patient INFERENCE Limitation in physical movements NURSING DIAGNOSIS Impaired physical mobility related to neuromuscular impairment and decreased muscle strength as manifested by limited ability to perform motor skills, difficulty turning, and movement-induced tremor. RANK

JUSTIFICATION Impaired physical mobility is also an actual problem which also requires immediate management. The resources and interventions needed to manage the problem are available both to the nurse and the family which makes the problem easily modifiable as well. Having this problem eliminated will also decrease the chance of the remaining problems to happen. The family does recognize this as a problem, but only secondary to the first problem since this problem is also influenced by the patients previous conditions as well as her age.

cannot ambulate independently Functional level scale: 3 (requires help from another person and equipment device) PA findings (February 24, 2011): The patient has difficulty to turn her head to the right against nurse hand. The patient cannot raise her left shoulder against nurse hand. Presence of tremor in both upper and lower extremities when the extremity is slightly elevated from the bed Left upper and lower extremities cannot move The left side of the body is in the state of decorticate rigidity posture

Not able to flex and extend her left arm, 0/5 Not able to flex and extend her left wrist, 0/5 Not able to flex and extend left thigh, 0/5 Not able to flex and extend her left foot, 0/5 Subjective: The patient usually verbalized, makati when asked about her decubitus ulcer. The grandson verbalized, Kadalasan nung nasa bahay kami tinatawag nya ako pag masakit yung likod nya dahil nga dun sa decubitus ulcer nya sa likod. The grandson reported, dati ang laki-laki talaga nung sugat nya sa likod tapos

Destruction of skin layers

Impaired skin integrity related to decubitus ulcer stage I right scapula, stage II left knee and stage IV sacral area as manifested by destruction of skin layers, reports of itching and pain.

Impaired skin integrity is an actual problem. It is given the highest priority because it requires immediate attention and adequate interventions to eliminate further untoward consequences. The problem is easily modifiable since the knowledge, skills and time of the nurse are available to treat the problem. The cooperation and time of the client as well as the family are also available to help manage the

may mga itimitim pa, mas maayos na nga yung sugat nya sa likod ngayon kaysa dati. Objective: (+) pain (+) facial grimace Localized erythema around the decubitus ulcer PA findings (Feb. 24, 2011): Presence of edema, left hand, stage II. Presence of decubitus ulcer stage I right scapula appears to be dry Presence of decubitus ulcer stage II left knee pinkish-red in color with protruding pus formation Presence of decubitus ulcer stage IV sacral

problem. The occurrence of the other problems may also be prevented if this problem is eliminated as early as possible. Lastly, the family and the client recognize this as the main problem.

area pinkish-red in color with yellow debris (3 inches in length and 2 inches in width with 1 inch depth) Presence of skin breakdown in both lower extremities Dead left middle finger, yellowish nails bed in both toes Right big toenail is rough in texture; toenails are hard and immobile Subjective: Since hospitalization, the client was not given bath and does not receive any oral care. The grandson verbalized, hindi na napapaliguan si lola dito, wala naman kasi ako noon dito nung tinanung yung

Impaired ability to perform self-care practices

Self-Care Deficit in bathing/hygiene, dressing/grooming, feeding and toileting related to neuromuscular impairment, weakness and discomfort secondary to cerebrovascular accident (CVA)

Self-care deficit is a health-threatening problem; this problem occurs due to the first two prioritized problems. It is also easily modifiable since the resources of the nurse and the family are easily available. The knowledge and skills of the nurse in helping the client perform self-care

doctor ni lola kung pwede ba syang paliguan. Objective: (+) discomfort (+) body weakness Inability to feed self independently Inability to dress self independently Inability to bathe and groom self independently Inability to perform toileting tasks independently Inability to ambulate independently Her grandson is the one who gives her meal and fed her because she cannot eat by herself. The relatives clean the patients face with wet wipes. When her diaper

practices as well as the manpower from the family helps resolve this problem. Helping the client perform self-care practices will enhance the patients over-all hygiene and promote care.

is soaked, the relatives or the nurses on duty do perineal care. Subjective: The grandson verbalized, constipated sya lagi dito sa ospital. The relatives reported that the patient displays poor appetite. Objective: Insufficient physical ability Poor eating habits Inadequate oral hygiene Stool is greenishdark in color and wedge-like formed. Subjective: The relatives reported that the patient has difficulty swallowing and displays poor appetite. Objective: The client has no

Risk for constipation

Risk for constipation related to irregular defecation habits, poor eating habits, insufficient physical activity and inadequate oral hygiene

Risk for constipation is a potential problem. Treatment of the second problem, impaired physical mobility, will eliminate one of the causes of this problem which is insufficient physical activity. The concern is to prevent the occurrence of this problem and it may be done so through the knowledge and skills of the nurse as well as the assistance of the family in preventing this problem. Risk for aspiration is a potential problem. Aspiration may impede airway so prevention of this problem is of great concern. This may be prevented through management of problems 2 and 3 which

Risk for aspiration

Risk for aspiration related to impaired swallowing, right facial weakness and presence of nasogastric tube

teeth; she has dentures but she does not wear it. (+) right facial weakness The patient has difficulty to turn her head to the right against nurse hand. Presence of nasogastric tube

specifically includes proper positioning especially upon feeding. The nurses skills and knowledge in preventing aspiration as well as the support of the relatives are available thus increasing the chance of preventing this problem.