Nursing Goals/

essment Rationale Interventions Rationale Evaluation

Diagnosis Objectives

Subjective: Fatigue related to People who After 2 hours of Independent: After 2 hours of nursing
altered body experiences sleep nursing and and collaborative
“Pagod na pagod chemistry deprivation and collaborative - Identify presence of - To assess causative factors interventions, the goal
ako, gusto ko sana pain are likely to intervention, the client physical and psychological was fully met, the patient
ng mas madami have an will: disease states was able to express
pang oras sa overwhelming different methods and
pagpapahinga” as sustained sense of 1. Express different - Note daily patterns - Helpful in determining activities on how to
verbalized by the exhaustion and methods and activities patterns of activities alleviate fatigue and
client. decreased capacity on how to alleviate participate in
for physical and fatigue - Evaluate need for - To determine impact on life recommended treatment
Objective: mental work as individual program were fully met.
usual. 2. Participate in assistance/assistive device
• Not enough recommended
energy for treatment program - Measure physiological - To determine degree of
daily activities response to activities like fatigue
• Chemotherapy changes in blood pressure,
heart and respiratory rate

- Establish realistic activity - Enhances commitment to

goals with client promoting optimal outcomes

Reference: - Plan care to allow - To maximize participation

Nurse’s Pocket individually adequate rest
Guide edition 10 periods. Schedule activities
Marilynn E. for periods when client has
Doenges the most energy

- Instruct in stress- - To assist client to cope with

management skills of fatigue and manage within
visualization and relaxation individual limits of ability

Dependent:

- Refer to physical/ - To maintain/ increase

occupational therapy for strength and muscle tone and
programmed daily exercise to enhance sense of well-
and activities being

- Refer to counselling - To promote wellness

 Assessment Nursing Rationale Goals/Objetives Nursing Interventions Rationale Evaluation
Diagnosis

Subjective: Activity Insufficient After 6 hours of Independent: After 6 hours of nursing

intolerance physiological; or nursing intervention,
“Mabilis akong related to psychological intervention, the 1. Note presence of factors - To identify causative goal met, as evidence by
mapagod ngayon, generalized energy to endure or client will state contributing to fatigue factors client’s able to state
tingin ko kailangan weakness complete required understanding of understanding of and
ko pa ng sapat na secondary to or desired daily and willingness 2. Evaluate current limitations - Provides comparative willingness to cooperate
lakas para magawa underlying activities. to cooperate in baseline in maximizing activity
ko yung mga disease process maximizing level
karaniwang activity level 3. Have patient perform self- - Activities will help patient
ginagawa ko” as care activities. Begin slowly and regain health
verbalized by the increase daily, as tolerated.
client.
4. Provide emotional support - To help improve patient’s
Objective: and encouragement self-concept and motivation
to perform activities of daily
• Limited living.
movement
 5. Note treatment-related - To identify precipitating
factors, such as side factors
Nurses Pocket effects/interactions of
Guide Ed.10 medications
Marilynn E.
Doenges, page 65. 6. Adjust activities - To prevent overexertion

7. Plan care with rest periods - To reduce fatigue

between activities

8. Assist with activities and - To protect client from

provide client’s use of assistive injury
devices

9. Encourage client to maintain - To enhance sense of well-

positive attitude; suggest use of being
relaxation techniques

Nurses Pocket Guide Ed.10

Marilynn E. Doenges, page
66-67.
 Goals/
Cues/Needs Nursing Diagnosis Rationale Interventions Rationale Evaluation
Objectives

Subjective: Risk for infection People at risk After 30 Independent: After 30 minutes
related to for infection are minutes of of nursing and
“Kakagaling ko lang pharmaceutical those whose nursing and - Monitor WBC count - Elevated total WBC collaborative
sa pagpapachemo” agents and natural defense collaborative count indicates infection. interventions, the
as verbalized by the immunosuppression mechanism are intervention, the goal was fully
client. inadequate to patient will be - Wash hands before doing any - To decrease transfer of met as evidenced
protect them able to procedure pathogens by the patients
from the understand how understanding of
inevitable to recognize - Teach patient how to - Hand washing prevents how to recognize
injuries and early signs and properly wash hands before spread of pathogens to early signs and
exposures that symptoms of and after meals and after using other objects and food. symptoms of
Objective: occur infection to bathroom, bedpan, or urinal. infection.
• Inadequate throughout the allow for
immunity course of living, prompt - Instruct patient to report - Diarrhea or loose stools
• Chemotherapy usually occur if treatment and to incidents of loose stools or may indicate need to
• Increased the remain free diarrhea. discontinue or change
environmental integumentary from it. antibiotic therapy.
exposure system breaks.
• IV devices - Provide reverse isolation as - Reduce risk of cross-
• Invasive indicated contamination
procedure
- Monitor visitors/caregivers - To prevent exposure of
(Reference: client
Nursing Care
Plan; Gulanick, - Review individual nutritional - To promote wellness
Myers; p. 108) needs, appropriate exercise
program, and need for rest

Dependent:

- Assist with medical - To reduce existing risk

procedures factors

- To determine
- Administer and monitor effectiveness of therapy
medication regimen and note and presence of side
clients response effects.
ASSESSMENT NURSING RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

SUBJECTIVE: Imbalanced nutrition Intake of nutrients After 3 days of -Determine the ability -it can be the After 3 days of
“wala akong ganang kumain” as less than body insufficient to meet nursing intervention to chew, swallow, and factor than can nursing intervention
verbalized by the requirements r/t metabolic needs r/t inability the client will be taste. affect ingestion the client was able
patient. to digest food because of able to: to:
inability to digest of nutrients
food because of physiological, physical -demonstrate -ascertain
-to determine
-demonstrate
OBJECTIVE: factors. progressive weight understanding of progressive weight
-weight from kg to kg physiological, gain individual nutritional what info to gain
-weakness physical factors. -be free of signs of needs provide to the -be free of signs of
-constipation malnutrition client malnutrition
-pale conjunctiva -verbalize -assess weight, body -provide -verbalize
-restlessness understanding of build strength comparative understanding of
causative factor baseline causative factor
when known and -note total daily intake -to reveal when known and
necessary changes that necessary
interventions should be made interventions
-demonstrate -demonstrate
in client’s dietary
behaviours and behaviours and
lifestyle changes to -encourage to choose
intake. lifestyle changes to
regain or maintain foods that are -to stimulate regain or maintain
appropriate weight appealing appetite appropriate weight
-consult the dietician -for long term
as necessary needs
-weigh weekly and -to monitor
document results effectiveness of
dietary plan