ASSESSMENT S: "Dugay naman ni siyang sige gahigda," as verbalized by the S.O of the patient.

O: Received patient lying on bed, asleep. - redness on the sacral area - senile skin turgor - client is very dependent to her S.O - patient seldoms sit in her wheelchair - patient is always seen lying on bed and asleep; cannot speak and always forget to chew or swallow her food.

DIAGNOSI S Risk for impaired skin integrity related to physical immobiliza tion secondary to stroke.

SCIENTIFIC BASIS Pressure ulcers may be caused by inadequate blood supply and resulting reperfusion injury when blood reenters tissue. A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood flow to affected areas. Within 2 hours, this shortage of blood supply, calledischemia, may lead to tissue damage and cell death. The sore will initially start as a red, painful area, which eventually turns purple. Left untreated, the skin may break open and become infected. Moist skin is more sensitive to tissue ischemia and necrosis and is also more likely to get infected.

PLANNING After 3-4 hours of nursing interventions, the patient will be able to maintain skin integrity as evidenced by intact skin.

INTERVENTIONS
INDEPENDENT: 1. Strictly follow the implementation and posting of a turning schedule, restricting 2 hours or less and time in ome position to customizing the schedule to patient's routines and caregiver's needs. 2. Encourage implementation of pressure-relieving devices such as pillows on bony prominences specially on the sacral area. 3. Maintain functional body alignment. 4. Increase tissue perfusion by massaging around affected area. 5. Clean, dry, and moisturized skin, especially over bony prominences, twice daily or as indicated by incontinence or sweating. 6. Encourage adequate nutrition and hydration.

RATIONALE

EVALUATION > After 3-4 hours of nursing interventions, patient was able to maintain skin integrity as evidenced by intact skin without lesions or wounds.

1. A schedule that does not interfere with the patient's and caregiver's activities is most likely to be followed.

2. This will reduced pressure because they are made of foam. 3. To distribute he bodies weight equally. 4. Massaging reddened area may damage skin further. 5. Prevent development of bedsores.

6. If deficient caloriesprotein and fluids on the diet, there would be decrease on tissue tolerance and more vulnerable to lower amount of pressure. 7. So that caregivers will be guided on what to do lessen the risk of having pressure ulcers.

7. Teach caregiver the cause(s) of pressure ulcer development on pressure skin, especially over bony prominences shearing or friction against skin.

Footnote:
http://en.wikipedia.org/wiki/Bedsore

ASSESSMENT Subjective data: "Makalimot na siya unsaon pagtulon sa iyang pagkaon. Naa ra pirmi niya ibutang sa iyang baba," as verbalized by the S.O. of the resident. Objective data: Received resident lying on bed, awake. -resident is very dependent on her S.O. -resident is always seen lying on bed and asleep; cannot speak and always forget to swallow her food. -resident drools / spits out her food and water instead of swallowing it.

DIAGNOSIS Impaired swallowing related to neuromuscular impairment secondary to stroke.

SCIENTIFIC BASIS

PLANNING After 5-10 days of nursing interventions, the resident will be able to have adequate food and fluid intake and will be from aspiration.

INTERVENTIONS
INDEPENDENT: 1. Assess for signs and symptoms of impaired swallowing. 2. Place the resident in High-Fowler's position for meals and snacks, head and nexk should be tilted forward slightly.

RATIONALE
1. To provide better and effective interventions for swallowing.

EVALUATION The resident was free from any aspiration and is taking adequate food and fluids.

2. To facilitate elevation of the larynx and posterior movement of the 3. Provide oral care before tongue. meals and snacks. 3. Oral care stimulates sensory awareness and 4. Assist resident to select salivation, which food that require little or facilitates no chewing and are easily swallowing. swallowed. (e.g. oatmeal) 4. To improve 5. Instruct S.O. of resident ability to swallow. to avoid mixing foods of different texture in his/her mouth at the same time. 5. To improve 6. Avoid serving foods ability to swallow. that are sticky. 7. Serve foods / fluids that are hot or cold instead of 6. To improve room temperature. ability to swallow. 8. Encourage resident to concentrate on the act of swallowing; provide verbal cueing as needed. 7. The more extreme temperature stimulate the sensory receptors

-observed difficulty in chewing and swallowing.

and swallowing 9. Gently stroke the reflex. resident's throat when she is swallowing. 8. To improve ability to swallow.

9. To improve ability to swallow.

ASSESSMENT
Subjective data: "Anhi na siya malibang ug mangihi sa iyang diaper," as verbalized by the S.O. of the resident. Objective data: Received patient lying on bed, asleep. -resident is always seen lying on her bed; cannot speak and always forget to swallow her food. -resident is wearing diapers. -diapers is change once everyday, depending if the resident has defecated.

DIAGNOSIS
Risk for impaired skin integrity related to prolonged periods of using diapers secondary to incontinence.

SCIENTIFIC BASIS

PLANNING
Long term: After 6-10 days of nursing interventions, resident will be able to maintain optimal skin integrity. Short term: After 30 minutes, the resident's caregiver will be able to understand the importance of proper skin hygiene and demonstrate measures to prevent skin breakdown.

INTERVENTIONS
INDEPENDENT: 1. Inspect area for presence of rash and assess for pruritus.

RATIONALE
1. Pruritus can be caused by dry skin. Rashes are evidences of allergies from diaper use.

EVALUATION
Resident's skin remained intact as evidenced by no redness and absence of skin breakdown.

2. Instruct caregiver to put on 2. Restrictive clothing / diapers not too tight or too diapers can increase loose. risk for skin breakdown. 3. Teach caregivers factors important to skin integrity: nutrition, hygiene and early mobolity. 4. Stress the importance of not scratching the skin. 5. Keep fingernails short. 6. Instruct the caregiver to change diapers frequently and not only as needed. 7. Encourage adequate nutrition and hydration. 3. Each factor contribute to preventing skin breakdown or ensuring successful skin healing. 4. Scratching can cause lesions and open sores. 5. Prevent skin breakdown from scratching. 6. To prevent skin breakdown. The urea in the urine turns to ammonia within minutes and is caustic to skin. 7. Adequate nutrition and hydration can help

maintain skin integrity.

ASSESSMENT
Subjective data: "Di na siya musulti kasagaran, mutando nalang siya," as verbalized by the S.O of the resident. Objective data: Received resident lying on her bed, asleep. - resident is always seen lying on her bed; cannot speak and always forget to swallow her food. - resident attempts to open mouth and speak but no words will come out. - resident responds through nodding her head.

DIAGNOSIS
Impaired verbal communication related to inability to modulate speech secondary to stroke.

SCIENTIFIC BASIS

PLANNING
Short term:

INTERVENTIONS
INDEPENDENT: 1. Face the resident when communicating with her, listen and watch them closely.

RATIONALE

EVALUATION
Resident has communicatio n skills and demonstrated understanding even if she cannot speak.

1. To facilitate communication. enhanced

A. Resident will use alternative 2. This may give you a hint on methods of 2. Listen carefully. Volidate what the resident needs or communicatio verbal and nonverbal wants to say. n effectively. expressions. Pay attention B. Resident will demonstrate understandin g even if not able to speak. Long term: Resident will be able to communicate without difficulty.
to their voice inflexion and body cues. 3. Always speak to the patient In a calm even voice. 4. Provide encouragement to the resident at all times when they are attempting to communicate with you. 5. Using an individualized approach, establish an alternative method of communication such as writing or using gestures. 6. Ask questions that require short answers, eyeblinks or nods of head. 7. Maintain eye contact at patient's level. 8. Spend time with the resident, allow time for resident to respond.

3. To facilitate communication. 4. To facilitate communication.

5. Alternative methods of communication are necessary when the resident is uanble to speak verbally. 6. To facilitate communication.

7. Good communication starts with good eye contact. 8. So that the patient knows that the nurse is willing to listen and take time with her.

9. Anticipate and provide for patient's needs.

9. Helpful in decreasing frustration when dependent on others and unable to communicate desires.

10. Talk directly to patient, 10. It reduces confusion and speaking slowly and anxiety. Tasks are needed to directly. be explained in every simple steps and presented one at a time. 11. Encourage caregiver to always talk/communicate with resident. 11. Consistency of approach by proffesional caregivers and promote effective communication.

ASSESSMENT Subjective data: Nisuka ko ganihang sayo sa buntag, as verbalized by the patient. Objective data: Received patient lying on bed, awake, conscious, responsive, coherent, not in respiratory distress and afebrile with remaining 100 ml of #9 of D5LR 1L @ 25 gtts/min infusing well @ the left hand. With the following V/S: T=36.6 PR=84 bpm RR=17cpm BP=120/70 mmHg

DIAGNOSIS Risk of fluid deficit volume related to active fluid loss vomiting.

SCIENTIFIC BASIS Fluid volume deficit is a condition when fluid loss exceeds intake and electrolytes in the human body become unbalanced. Cells do not have enough water to function properly when a fluid volume deficit develops from blood loss, vomiting or diarrhea. Excessive sweating and high fever can also lead to a deficit as a result of dehydration. During the early stage of dehydration, thirst and a dry mouth might be the only symptoms. Mild dehydration that results in a fluid loss deficit can generally be treated quickly by drinking water. As dehydration progresses, a person might become irritable, weak or dizzy. Sometimes the skin will feel dry and warm to the touch, and it may appear flushed. Decreased urine output

PLANNING > After 8 hours of nursing interventions, the patient will maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.

INTERVENTIONS INDEPENDENT: > Established rapport with the patient.

RATIONALE > For cooperation purposes of the patient to the health care provider.

EVALUATION

> After 8 hours of nursing interventions, the patient > Monitor vital signs. was able to Observe for temperature > Fever increases maintain fluid elevations or fever. metabolism and volume at a exacerbates fluid loss. functional level as > Monitor urinary output. evidenced by > Fluid replacement Measure or estimate fluid individually needs are based on losses from all sources such correction of current adequate as vomitus. urinary output deficits and ongoing with normal losses. specific > Evaluate clients ability to > Impaired gag and gravity, manage own hydration. stable vital anorexia, nausea are signs, moist among the factors mucous that affect clients ability to replace fluids membranes, good skin orally. > Encourage foods with turgor, and high fluid content. prompt > Relieves thirst and capillary refill. discomfort of dry mucous membranes and augments > Provide skin and mouth parenteral care. replacement.

and dark urine are other signs of mild dehydration, along with headache.

COLLABORATIVE: > Administer IV solutions, as indicated.

> Skin and mucous membranes are dry with decreased elasticity because of vasoconstriction and reduced intracellular water. > Crystalloids provide prompt circulatory improvement, although the benefit may be transient because of increased renal clearance.

Footnote: http://www.wisegeek.com/ what-is-fluid-volumedeficit.htm