2.1 NCP Patients Name: Judy Marie Muring Attending Physician: Dr.

Theodore Abrenilla Room No: 219 Age: 28 years old

Chief Complaints: feeling of discomfort due to enlarged mass at right parieto-occipital area Nursing Care Plan (Pre- Operative) Needs/ Problem/ Cues Physiologic Deficit Sleep Objective Cues: -expression less face -frequent yawning -hours 3-4 hours Subjective Cues: Kuwang usahay ako tulog tungod Nursing Diagnosis Disturbed Sleep Inadequate sleep enlarged 4.5x14.0cm) occipitoSignificance Objectives of Care Nursing Actions to sleep/ Rationale

Disruption in After 8 hours Measures the individuals r/t pattern sleep may chronic. of holistic establish patient rest pattern: 1. large rest intake as bedtime nursing care, optimal

1. Inadequate Pattern:

usual diurnal the and to: a.

of will be able instruct 1. This helps who fluid otherwise may before need to void during night. 179) 2. daytime physical activities indicated, instruct and increase 2. Activity reduces stress and promotes as sleep. the 179) (NCP, but Gulanick, pg. the (NCP, establish patient to avoid patient

mass (12.1x wakefulness

be optimal pattern

on the right temporary or sleep/ parietal area Such of which causes disruption when in position lying both supine subjective distress apparent impairment in functional abilities.

evidenced by 4-6 hours of

Gulanick, pg.

sleep is only discomfort

may result in sleep

patient to avoid

aning bukol sa ako ulo, as verbalized by patient. the

Factors can include

that affect

strenuous activity bedtime 3. recommend 3. Many sleep quiet an environment people before

sleep patterns temporary changes in routines such as emotional problems specifically depression or anxiety. (NCP, Gulanick, pg. 177)

conducive sleep/ rest

to better in cool, dark, (NCP, Gulanick, pg. 179) environment.

4.

suggest 4.

These

engaging in a activities relaxing activity provide before bedtime relaxation and (calm reading relaxation technique) music, distraction prepare mind sleep. 179) 5. nursing (bedtime position) comfortable provide 5. These aids aids promote rest. care, (NCP, Gulanick, pg. 179) to in care. to the and for (NCP,

enjoyable book, body

Gulanick, pg.

6. teach about 6. This allows possible causes patient of sleeping participate difficulties and their

optimal ways to (NCP, treat them Gulanick, pg. 180) 7. instruct on 7. nonsleep enhancement techniques pharmacological sleep enhancement techniques can be lifetime. (NCP, Gulanick, pg. 180) used a throughout Non pharmacologic

Psychologic Overload Disturbed

Body image is the attitude b. deal with

2. Change in Body Image: a person has or social involvement Objective Cues: change social involvement r/t feelings in about actual perceived function of the issues r/t or image

accept Measures of determine

to

or self- concept coping abilities body to accept/ deal issues of selfconcept r/t body image: 1. frequently visit 1. Provides and opportunities for listening to and

negative structure

-presence of about cystic lesion body at occipitoparietal area (12.1x 4.5x14.0cm) -change head structure Subjective Cues: Mauwaw sad usahay uban ang by patient. ko sa kay bukol, the in right

her all or parts of his/ her body. As important part of ones self- concept, body image disturbance can have a profound impact how individuals view overall selves. that individual places on body part or function may be important in determining The an importance their on an

acknowledge

the individual as concerns someone who is questions. worthwhile (NCP,

Gulanick, pg. 100) 2. encourage 2. To enhance of potential situations. (NCP, Gulanick, pg. 101) 3. alert staff to 3. monitor facial Because own they need to convey not the verbalization of handling anticipated conflicts

dako na kayo as verbalized

expressions and acceptance other nonverbal and behaviors revulsion when clients appearance is

the degree of disturbance than actual alteration in the structure or function. (NCP, Gulanick. Pg. 21) 4. at/ affected part the

affected. (NCP, Gulanick, pg. 101) encourage 4. To begin to touch changes body body (NCP, Gulanick, pg. 101) 5. help patient 5. to select and use minimize clothing/ makeup body changes and (NCP, Gulanick, pg. 101) 6. help the 6. Asking to body issues patient identify patient ways of coping remember that have been other useful past in the image enhance appearance. To into image. patient to look incorporate

and how they were managed may help the patient adjust to the current issue. (NANDA,

Doenges, pg. 23) 7. help the 7. Patient may changes that patient identify receive actual changes are not present or real, or they place unrealistic value or on a body structure function. (NANDA, Doenges, pg. 22) an

Knowledge Psychologic Deficit 3. Inadequate Deficient deficit is a lack cognitive of c. identify

known information about condition Objective Cues: -does answer directly questions been asked -ask questions twice Subjective Cues: Gipasagdan raman sad ni namo nagtu-o na dili kay mi ni

Knowledge: Inadequate information about the know

information or psychomotor skills

interferences to

Measures

to

learning identify to learning: with 1. determine 1. May not be emotionally or mentally capable time. (NANDA, Doenges, pg. 320) 2. provide 2. Encourages continuation of efforts. (NANDA, Doenges, pg. 321) 3. written guidelines provide 3. Reinforces info/ learning for process. Doenges, pg. 323) 4. patient knows begin 4. Limits information the sense of being already overwhelmed. and (NANDA, this patients ability physically, to learn

and specific interferences to actions them

the required for deal recovery, maintenance, or health promotion. Information should made available when the patient wants and needs it, the pace the patient determines, and using the teaching strategy most effective. (NCP, Gulanick, pg. 116) the patient seems be

condition r/t health unfamiliarity not with information the resources

positive reinforcement

patient to refer (NANDA, to as necessary

mutubo, as verbalized by the patient.

move to what Doenges, pg. the patient does 322)

not

know,

progressing from simple to complex 5. patient provide 5. Promotes of over active role for sense in control situation. (NANDA, Doenges, pg. 322) 6. provide 6. May assist with further information learning resources (magazines, newspaper, clippings) 7. objectives clearly learners terms learning process

about additional learning/ promote learning own (NANDA, Doenges, pg. 322) state 7. To meet learners in needs. (NANDA, Doenges, pg. 321) at pace.