ASSESSMENT NURSING PLANNING SELECTIVE IMPLEMENTED RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS INTERVENTIONS

SUBJECTIVE: Activity in After one INDEPENDENT: INDEPENDENT: GOAL

tolerance week of PARTIALLY
“parang hinang related to nursing  Encouraged  Encouraged  To reduce MET.
hina siya” as generalized interventions, adequate rest adequate rest cardiac
verbalized by the periods periods workload Patient was able
body the patient
patients mother.  To reduce to maintain
weakness will maintains energy
secondary to activity level activity within
OBJECTIVE:  Assist patient with  Assisted patient expenditure
present within ADL with ADL capabilities but
but avoid
illness. capabilities doing for was not able to

and absence patient what he eliminate body
of weakness can do; to weakness
increase self
esteem
 Planned activities  Planned  Encourage
for the patient activities for the physical
patient activity
consistent with
 Progress activity patients energy
gradually  Progressed resources
activity gradually  To prevent
over exerting
 Encourage ROM the heart and
exercises  Encouraged ROM promote short
exercises range goals
 To maintain
muscle
strength and
joint range of
motion
 ASSESSMENT NURSING PLANNING SELECTIVE IMPLEMENTED RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS INTERVENTIONS

SUBJECTIVE: Fluid Within 2 days GOAL MET

volume of providing
“parang dehydrated deficit r/t nursing care,  Maintain accurate  Maintained  patient may reduce AS
na sya” as severe will maintain fluid intake during EVIDENCED
Intake and Output accurate Intake periods of crisis
verbalised by the dehydration fluid and BY
and Output because of malaise,
patients mother to consider electrolytes anorexia,and so on
electrolyte volume at a ABSENCE OF
imbalance functional SIGNS OF
OBJECTIVE:  .reduction of
2˚ Acute level as circulating blood SEVERE
 Monitor  Monitored
Gastroenteriti evidenced by: volume can occur DEHYDRAT-
 Watery,loose v/s,comparing v/s,comparing from ↑fluid loss
stool(6x/day) s - will defecate ION
with patient’s with patient’s resulting in
in mod. amt semi-formed hypotension and
stool at lest 2
normal/ previous normal/
 Vomited tachycardia
5x/shift with times a day readings previous
sticky - will readings  symptoms reflective of
vomitus in DHN/
manifest hemoconcentration
scanty amount moist lips and  Observe for  Observed for with consequent
 Sunken mucous fever, changes in fever, changes vasoocclusive state.
eyeballs noted membranes LOC,skin turgor, in LOC,skin
 Dry lips & and capillary dryness of skin
mucus turgor,
refill in 2-3 and mucous dryness of
membrane seconds
noted. membranes, pain. skin and
mucous
membranes,  replaces
pain. losses/deficits. Fluids
 Administer fluids must be given
as indicated  Administered immediately to
fluids as decrease
hemoconcentration a
indicated prevent further
interaction
ASSESSMENT NURSING PLANNIN SELECTIVE IMPLEMENTED RATIONALE EVALUATION
 DIAGNOS G INTERVENTIONS INTERVENTIONS
IS

SUBJECTIVE: Acute pain After  Encourage  Encouraged GOAL MET

“masakit po yung related to 2hours of patient to patient to  To determine
tiyan ko” as present nursing verbalize verbalize the extent of PATIENT
illness feeling of pain the WAS ABLE
verbalized by the interventio feeling of
pain patient is TO
client n the pain
feeling and VERBALIZE
patient will how the
Pain described by RELIEF OF
verbalize patient copes
the client as up with it PAIN
relief of
pinching like pain
pain  Instruct in use  Instructed in
(pain scale not  Relaxation
applicable) of relaxation use of
helps to
techniques relaxation decrease the
OBJECTIVE: such as techniques patients
focused such as perception of
 (+) facial breathing or focused pain
grimace listening to a breathing or
 (+) guarding story etc. listening to a
behaviour at  Place patient story etc.
the abdomen in semi  Placed  To minimize
fowlers patient in pressure on
position semi fowlers the abdomen
 Encourage position
 To divert
diversional  Encouraged attention of
activities diversional the patient
such as activities from pain
watching tv such as
etc. watching tv To promote rest
 Maintaine etc. will help reduce
bed rest  Maintained pressure on
bed rest abdomen.