ASSESSMEN DIAGNOSI PLANNING INTERVENTIONS RATIONALE EVALUATIO

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Subjective: Fatigue related to Long term: 1.Monitor vital signs. -To evaluate fluid status and Goal met.
decreased cardiopulmonary response t The patient reported
• “Madali lang metabolic energy After 48 hrs. of nursing o activity. improved sense of
akong napapagod” production and intervention, patient will energy.
as verbalized by the increased energy report improved sense of 2. Plan interventions that allow -To maximize patient
patient. requirements energy as evidenced by patient to perform with adequate participation The patient was able
- Ability to do rest periods. to identify measures
• (+) body malaise
usual to improve energy.
routines/ADLS’s 3.Schedule activities in periods whe -To conserve patient’s
. n client has the most energy. energy.
Objective: - Increase activity
performance 4.Encourage patient to do whatever
- Absence of body possible such as self-care, walking -To manage patients limit
•Inability to do usual
routines malaise within ward premises and of ability.
interacting with family.
•Decreased activity
performance 5. Instruct methods to conserve -To conserve and maximize
energy such as sitting when doing patient’s energy.
daily care or other activities.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: INDEPENDENT
Disturbed sleep Pt. will report of 1. Determined client’s usual sleep - To identify appropriate Goal not met, the
“ Nagigising ako pattern related to improved sleep by the habits and changes. interventions. patient still does not
every 2 hours tuwing frequent urination next 24 hours, as report of improved
gabi kasi ihi ako ng evidenced by; 2. Listened to reports of sleep - Helps clarify client’s sleep, the patient still
ihi,” as verbalized by quality. perception of sleep quantity. reported of
the patient. - continuous interrupted sleep, the
uninterrupted patient verbalize
sleep 3. Performed monitoring and care - Allows for longer periods slight improvement
Objective: - Pt. will verbalize activities without waking client of uninterrupted sleep, quality of sleep, the
improved quality whenever possible. especially during night. patient stated not
- with 4-5 times of sleep well rested, the
frequent urination - Statement of patient demonstrates
every shift; feeling well 4. Promoted use of bedtime rituals frequent yawning,
amounting 50-100 rested such as drinking a glass of milk - Promotes relaxation and the patient wakes up
ml each urination; - Reports of before sleeping. readiness for sleep. frequently during
with Intake of 600 ml waking up less night.
and output of 500 ml frequently during
of urine. the night 5. Provided warm bath and
massage.
- With light yellow - Increases the effect of
urine. relaxation.
6. Improved environment by
reducing noise and dimming the
lights. - Provide a situation
conducive to sleep.
7. Provided bedtime care such as
back massage. - to promote physical
comfort.

8. Encouraged the patient to void

before sleeping. - Voiding before bedtime
may limit the sleep
disturbance.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE Imbalanced Nutrition: After 8 hours of nursing 1. Assessed the client’s - Due to excess fluid Goal met.
- Reports having weight. volume and low
little desire to More Than Body interventions, patient basal metabolic The patient was able to
exercise. Requirements related will be able to: rate, clients with
hypothyroidism verbalize accurate
to excessive intake in
- verbalize accurate experience weight information about
relation to metabolic gain and difficulty
information about benefits of weight loss
OBJECTIVE needs losing extra
- Sedentary benefits of weight loss. weight. and demonstrated
lifestyle appropriate selection of
- Eating in - demonstrate 2. Assessed the client’s - Clients with meals or menu planning
response to appetite. hypothyroidism
appropriate selection of
boredom have decreased toward the goal of
- Triceps skin meals or menu planning appetite. weight reduction.
fold >25 mm toward the goal of
- Height: 5‘8 3. Provided a food - Looking into the
weight reduction.
- Weight: 295 diary to the client. client’s food intake
lbs. over the 24 hours
- BMI: 44.8 will provide a
(Obese) baseline data for an
individualized
nutritional plan for
the client’s
changing
metabolic needs.

4. Educated the client - Teaching the client

and family regarding and family will
body weight changes make them
in hypothyroidism. understand the
 opposite
relationship
between appetite
and weight gain in
hypothyroidism.

5. Provided assistance - Due to a decrease

and encouragement energy levels, the
as needed during client will need the
mealtime. support to ensure
the adequate intake
of essential
nutrients.

6. Encouraged the - When thyroid

client to follow a hormone levels are
low-cholesterol, low, the body
low-calorie, low- doesn’t break
saturated-fat diet. down and remove
bad cholesterol as
efficiently as usual;
Also, since the
client has slow
metabolism, he/she
requires fewer
calories to support
metabolic need
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION