Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective cues: Risk for glucose level Short Term: 1. Establish Rapport 2. To gain the cooperation of After 1 hour of nursing
“Normal talaga sa deficit After 1 hour of nursing the patient and trust. intervention the patient will
akin ang mataas ang intervention, the patient will acknowledged factors that lead
sugar,” as acknowledge factors that may 2. Assessed vital signs 3. For baseline data. to unstable glucose level.
verbalized by the lead to unstable glucose
patient. level. 3. Assessed signs of 4. Polydypsia (thirst),
hyperglycemia polyphagia (hunger), and Long term:
Objective cues: Long term: polyuria (urination) Patient’s glucose is maintained
 BGM- pre- After 1 day of nursing . in 80-120 mg/dL.
meal 198 intervention, the patient will  No signs of
mg/dL post- be able maintain glucose in hyperglycemia.
meal 249 satisfactory range. Blood 4. Assessed blood 5. Patient BGM should be 80-
 Blurry glucose is maintained in glucose level pre 120.
vision normal level . and post meal.
 Body
weakness 5. Assessed patient 6. Adherence to dietary
 Headache eating pattern. guidelines may result to
 tremor fluctuation of BGL.

6. Assessed patient 7. Diet plan helps controlling

knowledge and BGL.
understanding on
prescribed diet.

7. Discussed 8. Patient needs to understand

importance of the relationship of exercise,
balance exercise food uptake and blood
with food intake. glucose level.
Collaborative:
1. Administer insulin
as prescribed.
ASSESSMENT DIAGNOSIS
Subjective: Ineffective tissue
perfusion: Cerebral
“Nahihilo ako” as related to vasoconstriction
verbalized by the pt. of blood vessels
secondary to
Objective: Hypertension
Cold hand and feet
Vital signs taken as Inference:
follows: (Increased cardiac output
BP: 160/100 mmHg that injures the endothelial
RR: 27 cells of the arteries and
PR: 91 BPM the action of
Temp: 36.8 prostaglandins.
Alert and Oriented Vasoconstriction occurs
and blood pressure
increases.)
PLANNING INTERVENTION
Short term: Independent NI
After 30 mins to 1 hour of 1. Monitored vitals signs of
NI patient blood pressure patient especially the BP.
will decrease from
160/100 mmHg to 120/80 2. Maintained in bed, instructed
mmHg. to have enough rest in semi
fowler’s position
Long term:
After 2 hours of NI 3. Maintained on low fat, low
patient will be able to salt diet. Restricted water intake.
have the knowledge on
how to prevent
hypertensive episode.
4. Gave health teachings
 Determined and
discussed modifiable risk
factors that can worsen
condition.
 Advised to monitor BP
regularly.
Dependent NI
-Administered irbersartan
(antihypertensive drug) as
ordered.
RATIONALE EVALUATION
Short Term:
-To know the baseline data After 30 mins-1 hour of NI,
patient’s blood pressure
decreased from 160/100
-Restricted activity reduces mmHg to 120/90 mmHg.
oxygen demand of the
heart and other organs
Long term:
-Sodium tends to be After 2 hours of NI, patient
excreted at a faster rate. was able to maintain his
-To reduce edema that may BP in a normal range and
activate RAAS. without signs of
hypertension.
-Knowledge is the key to
prevent hypertension.
-To control the BP and to
avoid other complication.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Fluid volume excess r/t Short term: 1. Established rapport -To assess participating Short term:
“Parang bumibigat and paa decrease glomerular After 4 hours of NI, and gain trust. After 4 hour of NI, patient
ko” verbalized by pt. filtration rate and sodium patient will demonstrate had demonstrated behavior
retention behavior of self- 2. Monitored and recorded -To obtain baseline data. of self-monitoring fluid
Objective: monitoring fluid status and VS status and reducing
edema Interference: reduce occurrence of fluid occurrence of fluid excess.
Hypertension (Renal disorder impaired excess 3. Noted amount of fluid -To monitor fluid retention
BP 160/100 mmHg glomerular filtration that intake and output from all and evaluate degree of
Weight 78kg resulted to fluid overload. Long term: sources. excess. Long term:
Which pushes into After 4 days of NI, BP will After 4 days of NI, patient
interstitial spaces that cause decrease from 160/100 to had manifested stabilize
edema and gain weight.) 120/80. 4. Compared current weight -For possible presence of fluid volume, normal
gain with admission or congestion. weight, and free from signs
previous stated weight. of edema.

4. Assessed patient diet -To prevent overload and

monitor intake and output

5. Maintained low sodium -Sodium attracts water

and minimized fluid intake.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Knowledge Deficit r/t After 2 hours of nursing 1. Established rapport Hypoglycemia may lead After 2 hours of nursing
“Hindi ko po unfamiliarity w/ the intervention, the patient to seizure, coma, and intervention, the patient
maintindihan ano talaga complications on the will be able to 2. Explained to the death. was able to demonstrate
yung sakit ko,” as disease demonstrate knowledge patient the importance of knowledge of symptoms
verbalized by the patient. of symptoms and medication compliance. and possible
possible complications of To make the patient complications of his
his condition. understand the effects of condition.
3. Explained the disease his non-compliance with
process and possible medication
complications of the
disease. To make the patient
understand how the
disease was developed
and the possible
4. Provided health complications that may
teaching regarding the arise
prevention of
complications. To prevent possible
complications
5. Evaluated patient’s
knowledge.

To identify the
understanding of the
patient
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
RATIONALE
Risk for Type 2 diabetes Short Term: 1. Advised patient to Physical activities increases risk of Short Term:
infection mellitus occurs After 8hrs of avoid strenuous getting wounded. Patient with DM has After 8hrs of nursing
when the nursing activities, especially poor wound healing which can interventions, the patient was
pancreas interventions, those that involved eventually lead to infection. able to identify interventions to
produces the patient will skin contact. prevent or reduce risk of
insufficient be able to infection.
amounts of the identify 2. Taught patient Minimize the risk for infection.
hormone insulin interventions to proper handwashing
and or the prevent or techniques
body’s tissues reduce risk of
become resistant infection 3. Encouraged A balanced diet is essential in reducing Long Term:
to normal or patient to eat a risk of infection After 2 days of nursing
even high levels balanced diet intervention the patient was
of insulin. This able to be free of infection.
causes high Long Term: 4. Encouraged To boost immune system
blood After 2 days of adequate rest
glucose(sugar) nursing
levels, which intervention the
can lead to a patient will be
number of able to prevent
complications if infection
untreated.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective cues: Disturbed sensory Short Term goal: 1. Identified name and Identification when entering room Short Term goal:
“Sobrang labo perception related to After 1 hour of purpose when entering helps the client to feel secure and After 1 hour of nursing intervention, the
na ng paningin poor visual acuity nursing client’s room. decreases social isolation. patient was able to verbalize understanding
ko” as intervention the of visual loss.
verbalized by patient will be able 2. Taught the patient This will help the client understand
the patient: to verbalize the etiology of his the physiology of his condition Long Term goal:
understanding of condition thereby increasing awareness of After 1 week of nursing intervention, the
Objective cues: visual concession. problem, and identifying the severity patient was able adapt to permanent visual
 Frequent to allow for establishment of a plan changes.
blinking, Long Term goal: of care.
squinting After 1 week of 3. Identified the
 Frequent nursing factors that worsens
rubbing intervention, the his vision
of eye patient will be able
to adapt permanent
visual changes. 4. Instruct patient or Reduced visual acuity puts patient at
significant others risk for injury.
regarding need for
maintain safe
environment.

5. Advise to consult Consultation with the proper health

with an care personnel is necessary to
ophthalmologist determine the severity of the
regarding severity of condition and the corresponding
condition and the need actions that should be taken.
for glasses.