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
Subjective Cues: related to post operative wound
secondary to Exploratory Laparotomy
As verbalized by the client
Potential
Gasakit kung mag giyo ko. Risk for disturbed sleep pattern related
to altered comfort secondary to
Nahadlok ko mag giyo. Exploratory Laparotomy
Moderate anxiety related to perceived
pain during movement secondary to
Exploratory Laparotomy
Potential
Risk for self-care deficit r/t pain during
movement secondary to Exploratory
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:
Pallor noted
Pale conjunctiva noted
Weight of 33 kg.
Laboratory results
Albumin of 1.8 g/dL (3.5-5.0
g/dL)
RBC of 3.90 (4-5.30 L)
requirements Imbalanced Nutrition: Less than body
requirements related to inability to
absorb foods secondary to Bowel
Obstruction
Potential
Risk for infection related to
imbalanced nutrition secondary to
Bowel Obstruction
Disturbed body image r/t presence of
stoma secondary to Colostomy
Potential
Risk for situational low self-esteem r/t
body image disturbance secondary to
Colostomy

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