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onale – individualized program can be developed to meet particular needs/ deal with deficits in balance, coordination, strength. 
 Assist with electrical stimulation, e.g. trancutaneous electrical nerve stimulator (TENS) unit as indicated. 
Rationale – may assist muscle strengthening and increase voluntary muscle control as well as pain control. 
Evaluation 
 Goal met. After 3 days of duty patient maintains strength and function of affected body part and maintains skin integrity. 
Date: 
Subjective cues 
 “Murag pila na anhi kaadlaw na wala na siya kaligo” as verbalized by SO. 
Objective cues 
 Presence of unpleasant body odor 
 Patient is lying on bed, unconscious 
 Hair is dry, dandruff and nits noted 
 Dirty and long nails noted 
 Glasgow Coma Scale of 6 
• Eye opening – no response – 2 
• Motor response – extends abnormally – 2 
• Verbal response – no response – 2 
 On NGT feeding 
 On Intravenous Fluid at 60-70 microgtts/min 
 On 02 inhalation at 2-4 L/min 
 (+) Brudzinki’s sign 
 (+) Kernig’s sign 
Nsg. Dx 
 Self-care deficit r/t motor impairment as evidenced by poor personal hygiene 
Planning 
 After 8 hours of duty patient will have improved personal hygiene 
Intervention 
Independent: 
 Morning care rendered 
- trimmed nails 
Rationale- To promote personal hygiene and cleanliness 
  
Dependent  依据
 Consult with occupational therapist/ rehabilitation team 
Rationale- Identifying assistive devices/equipment enhances level of overall function and participation in activities, enhancing sense of well-being and viewing self as a capable individual. 
Evaluation 
 Goal not met. After 8 hours of rendering nursing care, patient is still have presence of unpleasant body odor, dry hair with dandruff and nits. 
Subjective cues 
 “Maam unsa man ang Meningitis?” as verbalized by SO 
Objective 
 Request for information about meningitis by SO 
 On NGT feeding 
 On Intravenous Fluid at 60-70 microgtts/min 
 On 02 inhalation at 2-4 L/min 
 Glasgow Coma Scale of 6 
• Eye opening – no response – 2 
• Motor response – extends abnormally – 2 
• Verbal response – no response – 2 
Nsg. Dx. 
 Knowledge Deficient r/t unfamiliarity with information resources as evidenced by request for information about meningitis. 
Planning 
 After 8 hours of duty patient’s SO will manifest increased knowledge and awareness about meningitis 
Intervention 
Independent 
 Evaluated type/ degree of sensory-perceptual involvement 
Rationale- deficits affect the choice of teaching methods and content/ complexity of instruction 
 Included SO/Family in discussions and teaching 
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