BSN 2 Sec 3 Grp B

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: Self-esteem is defined STO: Dx: STO:

as the way an
"Sana magka anak individual thinks about Within 8 hours of  Assess the patient’s  Patients with self-esteem (Goal Met)
pa kami ". as himself or herself, and effective nursing feelings of comfort and issues may appear as
verbalized by interventions, the content with his or her though their actions are Within 8 hours of
how good he or she effective nursing
patient feels. Positive self- patient will be able to: own performance. not in keeping with their
own personal, moral, or interventions,
Objective: esteem develops
a) Will able to ethical values; they may the patient
when a person feels verbalize her recognized the
 Mood is good and capable of also deny these
feelings impact/effect
dysphoric responding to b) Discuss any behaviors, project
blame, and rationalize of the low self
and tearful challenges and hard/angry
at times, but feelings about personal failure. esteem, able to
stressors. Nevertheless, verbalize her
client is the loss of her
when a person exhibits feelings and
responsive baby.
and mild to a c) Recognize the  The patient may have inquire proper
remarkable shift in the  Assess how competent
cooperative. impact/effect developed the ability to help.
 Pre orbital view of himself or patients feel about their
of low self carry out personal
puffiness. herself such as esteem and ability to perform and
carry out their own and responsibilities despite
 Staring negativity about self, inquire need for
distress help. others’ expectations. low self-esteem. This LTO:
low self-esteem may be a positive
develops. Low self- indicator of the (Goal Met)
Nursing Diagnosis: esteem can reduce patient’s potential for
the quality of a successful improvement Within 24 hours
Low self esteem person’s life in many LTO: of effective
of self-esteem.
related to death of different ways, nursing
an embryo as Within 24-48 hours of
including negative interventions,
evidenced by effective nursing
feelings, fear, the patient’s
Expressions of interventions, the
helplessness and relationship problems, patient will:
uselessness or low resilience. This
change in self-esteem
is a temporary phase
in response to feeling
helpless to control the
current situation.
SOURCE:
https://nurseslabs.com
/situational-low-self-
esteem/
mood will be
back to normal,
a) Patient reports  Assess for presence of  Ongoing grief may will think positive
progress in unfinished grief. hinder the patient’s
about the future
current ability to move forward and reports
situation. in life. progress in
b) Look Tx: current
toward/plan for situation.
future, one at a  Provide privacy.  Private discussions need
time. to take place in a
c) Mood will back setting where the
to normal patient is free to express
feelings without being
overheard.

 Apply active listening and  These communication

open-ended questions.
methods permit the
patient to verbalize
interests, concerns,
worries, and thoughts
without interruption. This
technique will convey a
sense of respect for the
patient’s abilities and
strengths in addition to
recognizing problems
and concerns.
 Spend time with the
patient; set aside enough
time so that the encounter
is calm and deliberate.
Edx:
 Educate the patient to join
in activities anticipated to
result in healthy self-
esteem.
 Encourage the patient to
express if he or she is able
to associate these
changes to a specific
event in his or her life.
 Encouraged verbalization
of feelings
 The patient needs to
explore options to
improve self-esteem by
substituting negative
behaviors with positive
actions.
 The patient needs to
explore options to
improve self-esteem by
substituting negative
behaviors with positive
actions.
 The patient may be
knowledgeable of up-
to-date situations that
negatively change his
or her self-concept.
 Help the bereaved to
recognize, actualize,
and accept the loss
ASSESSMENT:
1. Focus on your Nursing Diagnosis (Subjective and Objective cues should ALL be align with your problem)
2. Subjective data (preferably verbalization from the patient and must be in an open and close quotation otherwise if it is coming from the mother
or any significant other, it must be categorize as subjective data from a secondary source or an objective data [if it can be perceived by the
senses, verified by another person observing the same patient, and tested against accepted standards or norms] from a secondary source).
3. Objective data (start with the most obvious observation that is related to your nursing diagnosis to the less obvious, followed by abnormal vital
signs that are related to your problem and any laboratory results that are relevant to your problem)
4. For Nursing Diagnosis, use the 3-Part Statement: PES Format (Problem + Etiology + Signs and Symptoms) Three parts are joined together by
“related to” or “associated with” and “as manifested by” or “as evidenced by”
EXPLANATION OF THE PROBLEM:
1. Should be in paragraph form, it’s just like doing your pathophysiology but explaining in detail how the problem arise in relation to your objective
data and other signs and symptoms manifested by the patient that are related to your problem.
2. DO NOT FORGET to indicate your source as a basis in coming up with your explanation of the problem.
OBJECTIVES:
1. Must follow the concept of SMART (Specific, Measurable, Attainable, Realistic and Time bound).
2. STO (Short Term Goal). In theory it covers your acute care (till 6 months). But for our requirement we measure our STO within the shift (0 – 8 hours).
A better parameter would be using ranges of time depending on the planned activities.
3. LTO (Long Term Goal). In theory it covers your chronic care (6 months and above). But for our requirement we measure our LTO within the first day
to the third day or one rotation (24 – 72 hours). A better parameter would be using ranges of time depending on the planned activities.
NURSING INTERVENTION:
1. Dx (diagnostics) should be based on your SUBJECTIVE and OBJECTIVE DATA.
 2. Tx (therapeutics) should be arrange as ICDS (Independent nursing function, Collaborative [other health-care professional aside from the
physician], Dependent nursing function [physician/doctor], Supportive [Significant others, clergy/priest, and non-health care professional]
3. Edx (educative) should be based on the most needed by the patient that is relevant to the nursing diagnosis. (you can also base it on your STO
and LTO if there are educative goal)
RATIONALE:
1. It must be aligned with your nursing intervention and relevant to the case of you patient.
2. For the administration of medication, your rationale should be the indication of the drug in relation with the patient’s case.
EVALUATION/ EXPECTED OUTCOMES:
1. Evaluation for ACTUAL PROBLEM and your NURSING INTERVENTION should be past tense.
2. EXPECTED OUTCOME for POTENTIAL PROBLEM and your NURSING INTERVENTION should be future tense.
3. Should evaluate (GOAL MET, GOAL NOT MET or GOAL PARTIALLY MET) accurately and should be supported by results from your STO and LTO.
4. For expected outcomes (GOAL MET IF, GOAL NOT MET IF or GOAL PARTIALLY MET IF), and give parameters for the IF.
5. Should discuss or make recommendation/s for goal not met and partially met.

Always remember that NURSING PROCESS is SYSTEMATIC, PATIENT-CENTERED, GOAL-ORIENTED AND DYNAMIC.