Disturbed Sensory Perception related to cognitive deficits, sensory disturbances
Purpose: an increase in memory
with expected outcomes:
the patient can demonstrate the ability to improve memory, orientation and reduced agitated
Interventions and Rationale:
1. Introduce the name.
R /: help remember things that are important or essential.
2. Create a schedule of activities.
R /: The patient can remember the events and time.
3. Display photos of family, friends, and home.
R /: remembering self and family.
4. Make a simple memory exercises.
R /: to help improve memory.
5. Assess the patient's orientation.
R /: identifying patient orientation capabilities.
6. Call the patient by name.
R /: remember his own name.
7. The care givers should be the same person.
R /: easy to remember and more cooperative.
8. Perform an easy job on a regular basis.
R /: train the patient orientation.
Self-care deficit (eating, drinking, dressing, hygiene) related to changes in the process of thought
Purpose: improvement in the fulfillment of self-care behaviors
with expected outcomes:
the client can indicate a change in lifestyle for self-care needs.
identifying individuals / families that can help.
1. Avoid activities that can not be done by the client and help when necessary.
R /: the client in a state of anxious and dependent. This is done to prevent frustration and self-esteem.
2. Teach and support the client during the activity.
R /: support to the client during the activity can improve self-care.
3. Modify environment.
R /: to compensate for the inability to function.
4. Identification of bowel habits, encourage drinking, and increased activity.
R /: improving training and helps prevents constipation.
5. Collaboration: Provision suppositories and lubricants stool or a laxative.
R /: first aid to bowel function.
Imbalanced Nutrition less than body requirements related to inadequate intake and change in thought process.
Purpose: the client's nutritional needs are met
with expected outcomes:
understand the importance of nutrition for the body.
showed weight gain in accordance with the results of laboratory tests.
Interventions and Rationale
1. Evaluation of the ability of a meal.
R /: The client had difficulty in maintaining weight loss, dry mouth due to medications and have difficulty chewing and swallowing.
2. Observation / balanced body weight if possible.
R /: sign in weight loss and shortage of intake of nutrients to support the occurrence of catabolism problem.
3. Assess the function of the gastrointestinal system that includes voice bowel.
R /: the function of the gastrointestinal system is very important for the food.
4. Encourage fluid intake 2500 cc / day, as long as no heart problems.
R /: prevent dehydration due to ventilator use during unconscious and prevent constipation.
5. Continue laboratory tests indicated.
R /: provides precise information about the state of the nutrients needed by the client.
Purpose: an increase in memory
with expected outcomes:
the patient can demonstrate the ability to improve memory, orientation and reduced agitated
Interventions and Rationale:
1. Introduce the name.
R /: help remember things that are important or essential.
2. Create a schedule of activities.
R /: The patient can remember the events and time.
3. Display photos of family, friends, and home.
R /: remembering self and family.
4. Make a simple memory exercises.
R /: to help improve memory.
5. Assess the patient's orientation.
R /: identifying patient orientation capabilities.
6. Call the patient by name.
R /: remember his own name.
7. The care givers should be the same person.
R /: easy to remember and more cooperative.
8. Perform an easy job on a regular basis.
R /: train the patient orientation.
Self-care deficit (eating, drinking, dressing, hygiene) related to changes in the process of thought
Purpose: improvement in the fulfillment of self-care behaviors
with expected outcomes:
the client can indicate a change in lifestyle for self-care needs.
identifying individuals / families that can help.
1. Avoid activities that can not be done by the client and help when necessary.
R /: the client in a state of anxious and dependent. This is done to prevent frustration and self-esteem.
2. Teach and support the client during the activity.
R /: support to the client during the activity can improve self-care.
3. Modify environment.
R /: to compensate for the inability to function.
4. Identification of bowel habits, encourage drinking, and increased activity.
R /: improving training and helps prevents constipation.
5. Collaboration: Provision suppositories and lubricants stool or a laxative.
R /: first aid to bowel function.
Imbalanced Nutrition less than body requirements related to inadequate intake and change in thought process.
Purpose: the client's nutritional needs are met
with expected outcomes:
understand the importance of nutrition for the body.
showed weight gain in accordance with the results of laboratory tests.
Interventions and Rationale
1. Evaluation of the ability of a meal.
R /: The client had difficulty in maintaining weight loss, dry mouth due to medications and have difficulty chewing and swallowing.
2. Observation / balanced body weight if possible.
R /: sign in weight loss and shortage of intake of nutrients to support the occurrence of catabolism problem.
3. Assess the function of the gastrointestinal system that includes voice bowel.
R /: the function of the gastrointestinal system is very important for the food.
4. Encourage fluid intake 2500 cc / day, as long as no heart problems.
R /: prevent dehydration due to ventilator use during unconscious and prevent constipation.
5. Continue laboratory tests indicated.
R /: provides precise information about the state of the nutrients needed by the client.
