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Cues Problem Physiologic Behavioral: Nutrition: Less Than Body Requirements Acute Pain Altered ADL

The document lists several problems identified in a patient including nutrition less than body requirements, acute pain, risk for disturbed body image, altered activities of daily living, disturbed sleep pattern, activity intolerance, risk for infection, and risk for self-care deficit in toileting. It then provides cues, both subjective reported by the patient and objective observed, as well as physiological and behavioral problems related to each identified issue for the patient who had an exploratory laparotomy and bowel obstruction requiring an ileostomy. Potential risks are also listed for each problem.

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Aya Bolinas
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514 views3 pages

Cues Problem Physiologic Behavioral: Nutrition: Less Than Body Requirements Acute Pain Altered ADL

The document lists several problems identified in a patient including nutrition less than body requirements, acute pain, risk for disturbed body image, altered activities of daily living, disturbed sleep pattern, activity intolerance, risk for infection, and risk for self-care deficit in toileting. It then provides cues, both subjective reported by the patient and objective observed, as well as physiological and behavioral problems related to each identified issue for the patient who had an exploratory laparotomy and bowel obstruction requiring an ileostomy. Potential risks are also listed for each problem.

Uploaded by

Aya Bolinas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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LIST OF PROBLEMS

Nutrition: Less than body requirements


Acute Pain
Risk for disturbed body image
Altered ADL
Disturbed sleep pattern
Activity Intolerance
Risk for infection
Risk for self-care deficit: toileting

CUES PROBLEM PHYSIOLOGIC BEHAVIORAL

Date Identified: August 3, 2016 Actual Actual


Acute Pain Alteration in comfort: Acute pain Moderate anxiety related to perceived
Subjective Cues: related to post operative wound pain during movement secondary to
secondary to Exploratory Laparotomy Exploratory Laparotomy
As verbalized by the client
Potential Potential
Gasakit kung mag giyo ko. Risk for disturbed sleep pattern related Risk for self-care deficit r/t pain during
to altered comfort secondary to movement secondary to Exploratory
Nahadlok ko mag giyo. Exploratory Laparotomy Laparotomy

Objective Cues:
Pain scale of 8/10 ted
Facial grimace noted upon
moving no
Irritability noted
Restlessness
Pain upon moving noted
Anxiety noted
Guarding behaviour noted
Facial grimace during
movement noted

Imbalanced Nutrition: Less than body Actual Actual


Objective Cues: requirements Imbalanced Nutrition: Less than body Disturbed body image r/t presence of
Pallor noted requirements related to inability to stoma secondary to Colostomy
Pale conjunctiva noted absorb foods secondary to Bowel
Weight of 33 kg. Obstruction Potential
Risk for situational low self-esteem r/t
Laboratory results
Potential body image disturbance secondary to
Albumin of 1.8 g/dL (3.5-5.0
Risk for infection related to Colostomy
g/dL)
imbalanced nutrition secondary to
RBC of 3.90 (4-5.30 L)
Bowel Obstruction

Actual Actual
Subjective: Altered Activities of Daily Living Altered activities of daily living Situational low self-esteem r/t
As verbalized by the client: related to presence of ileostomy presence of ileostomy secondary
Kabudlay kung may ileostomy. secondary to Bowel Obstruction to Bowel Obstruction

Potential Potential
Indi ko kumportable magtulog
Risk for ineffective health Risk for impaired social
kung gab e.
maintenance related to aleration interaction related to alteration in
Objective Cues: in daily living secondary to daily living secondary to
Anxiety noted Ileostomy Ileostomy

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