Assessment Diagnosis Planning Intervention Rationale Evaluation

S Imbalanced After series of  Administer  To replace

 “di ako nutrition less nursing IVF as fluid loss
makakain than body intervention the ordered
ng requirements r/t patient will
maayos” as inability to ingest demonstrate  Monitor  For
claimed food or absorb progressive weight comparativ
O nutrients weight gain e data
 loss of because of toward goal
weight biological factors  Promote  To
from 52kg socialization enhance
to 46kg intake
 Provide oral
 With poor care before
muscle and after
tone meals

 Pale  Encourage
conjunctiva patient to  To
choose stimulate
 Limited foods that appetite
ROM are
appealing
 Weakness
 Limit fiber
 Poor skin or bulk if  Because it
turgor indicated may lead
to early
satiety
Assessment Diagnosis Planning Intervention Rationale Evaluation
S Fluid volume After series of  Administer  To replace
 “nagsusuka deficit r/t acute nsg imtervention ivf as fluid loss
ako” as fluid volume loss the client will ordered  To obtain
claimed as evidenced by maintain normal  Monitor vital baseline
vomiting fluid volume at a signs data
O functional level especially  To prevent
 With poor BP injury from
skin turgor  Provide dryness
 With facial frequent  For
grimace oral care comparati
 With dry  Monitor ve data
skin and daily weight  To
mouth  Promote conserved
 Pale and rest periods energy
weak in  Instructed to  To
appearance limit conserved
 Body unnecessary energy
malaise movements
noted  Note
 With appearance
greenish and severity
color of of vomiting
vomitus
 Vomits 5
times a day
 With BP of
100/60mmH
g
 Weight of
46kg
Assessment Diagnosis Planning Intervention Rationale Evaluation
S Acute pain r/t After series of  positioned  to feel After series of
 “Sumasakit nsg intervention comfortably comfortable nsg intervention
ang tiyan the patients on bed  to promote the patients
ko” pain will be  perform relaxation pain has been
As claimed lessen from 8 massage  to evaluate lessened as
to 5  assess pain level of pain evidenced by
 w/ pain location,  pain score from
score of 8 characteristi  To lessen 8 to 5 on the
out of 10 c, onset or the level of pain scale
at the pain duration, pain
scale frequency  Divertional
O and severity activities
 w/ facial  encouraged aids in
grimace verbalization refocusing
 weak in of feelings attention
appearance  encouraged and
 poor skin deep enhancing
turgor breathing coping with
 w/ distented exercise limitation.
abdomen  promoted  To lessen or
 irritable divertional temporarily
 w/ activity such relieved
abdominal as reading patients
guarding news paper level of pain
 rubs painful  administer
part analgesics
 restless as ordered
 w/ teary
eyes noted
Assessment Diagnosis Planning Intervention Rationale Evaluation
S Altered After series of  TSB rendered  To After series of
 “mainit thermoregulation nsg intervention  Encouraged to decreased nsg intervention
ang r/t presence of the pt loosened body heat the pt
pakiramda infection temperature will clothing’s  Because temperature has
m ko” as decrease from  Monitored increase been decrease
claimed 38.90C to 37.50C temperature clothing’s as evidences by
 Administered may affect temperature of
O fluid and body 38.90C to 37.50C
 w/ flushed electrolytes as temperatu
skin ordered re
 warm to  Administered  To restore
touch antipyretics as or
 irritable ordered maintaine
 limited  Emphasized d body or
ROM proper organ
 w/ hygiene function
temperatu And proper  To
re of wound care temporaril
38.90C per y relieved
axilla fever
 RR of  To prevent
35bpm infection
Assessment Diagnosis Planning Intervention Rationale Evaluation
S Risk for After series of  wound care  For After series of
 “Naoperahan infection r/t nursing done wound nursing
ako nung post surgical intervention the  observed for healing intervention the
sabado” incision pt and relatives signs of  To pt and relatives
O will know the infection in prevent was able to
 w/ post effective incision site further know the
surgical prevention for or wounds complicati effective
incision in the infection and  encouraged on prevention for
abdominal gain full deep  To infection and
area understanding breathing promote gain full
 w/ dressing to risk factor exercise comfort understanding
dry and intact  instructed  To to risk factor as
 w/ coughing prevent evidenced by
jejonostomy exercise wound proper
tube dehiscenc demonstration
 encouraged
connected to e or of wound
early
bed side eviscerati cleaning
ambulation
bottle  emphasized on
 w/ colostomy proper  For good
bag wound blood
 w/ IFC dressing, circulation
 w/ NGT proper  To
drainage hygiene prevent
 advised to infection
eat nutritious  To boost
food immune
especially system
food rich in and for
vitamin C good
 IFC and NGT wound
drain healing
properly  To
 Administer prevent
antibiotics as spread of
ordered infection
 To kill
bacteria’s
causing
infection
Assessment Diagnosis Planning Intervention Rationale Evaluation
S Ineffective tissue After 6 hours of  monitored  to know After 6 hours of
 “Nahihilo perfusion related nursing blood the nursing
ako” as to intervention the pressure q10 baseline of intervention the
claimed vasoconstriction patient blood  place in semi BP patient blood
O of blood vessel pressure will fowlers  good pressure was
 w/ BP of decrease from positioned venous decrease from
160/100 160/100 mmHg  established return 160/100 mmHg
mmHg to 120/80 safety  to avoid to 130/90
 PR of 96 mmHg precaution injury mmHg
 RR of 24  instructed to  lessen the
 limited minimize dizzeness
ROM unnecessary of the
 w/ NGT movement client
 w/  instructed to  because
jejonostom eat low fat fatty and
y tube and low salt salty food
 w/ diet can
colostomy  administered increased
bag antihypertensi blood
ve drug as pressure
ordered  to control
BP and
avoid
further
complicati
on
Assessment Diagnosis Planning Intervention Rationale Evaluation
S Activity Short term goal:  Assess pt.  To identify
 “hirap ako intolerance r/t After 6 hours of ability to pt. level of
kumilos post surgical nursing perform activity
kase incision intervention the task and
sumasakit secondary to pt. will report difficulty
ang colostomy activity tolerance accomplish
naopera w/ enhanced ing task.  To prevent
ko” as energy and will  Assisted to over
claimed participate in ADL exertion
O desired activities  Promote  To protect
 Weak in comfort client from
appearanc measures injury
e on the  To monitor
 Poor Long term goal: activity client
muscle After 3 days of  Develop respond to
tone nsg intervention and adjust activity
 With pale the patient will simple  So patient
skin and be able to move activity will be able
conjunctiv w/out asking like to rest prior
a assistance brushing to activity
 With his teeth  Depression
fatigability  Plan over
 Looks thin possible inability to
in activity perform
appearanc  Assess required
e emotional activities
 Irritable at response can further
times to change aggravate
 w/ NGT in physical the activity
 w/ status intolerance
Jejonostom  Provide  For energy
y tube rest conservation
 w/ IFC
 w/
 colostomy
bag

Assessment Diagnosis Planning Intervention Rationale Evaluation

S Pain r/t post After 8 hours of  assess the pt  to identify After 8 hours of
 “sumasakit surgical incision nursing perception, and assess nursing
at kumikirot as manifested intervention the level of the intervention the
ang naopera by pain a pain pt should understandin different pt level of pain
saken” as scale of 7 out of manifest a g and needs nursing has decreased
claimed 10 and (+) facial decrease in pain  monitored interventio as evidenced by
grimace scale from 7/10 vital signs n to ne pain scale of
 w/ pain to 4 out of 10 or including done 7/10 to 4/10 and
score of 7 lower pain scale  to assess (-) facial grimace
out of 10 in q10 the
the pain  encouraged effectivene
scale pt verbal ss of the
report during ndg
O and after interventio
 facial each nursing n and
grimace interventions obtain
noted  position pt baseline
 teary eyes comfortably for future
noted  encouraged compariso
 w/ post to do n
exlap diversional  Because
wound activities pain is
 w/ such as high
colostomy reading subjective
 w/ NGT news paper  To provide
 w/  administer comfort
analgesic as  To divert
 jejonostomy prescribe attention
tube from pain
 To
alleviate
pain

Assessment Diagnosis Planning Intervention Rationale Evaluation

S
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Uwi muna ako…… pasok muna ako…..

Assessment Diagnosis Planning Intervention Rationale Evaluation
S
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