ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
nauuhaw ako saka
nararamdaman kong tuyo
ang lalamunan ko ,as
verbalized by the patient.

Objective:
Poor skin turgor
CR= 5 seconds

Fluid volume deficit r/t
fluid loss through
vomiting and
increased body
temperature

After 1 hour, the patient
will be able to develop
feelings of relief and
alleviation from
dehydration.

Increased fluid intake.



Measured and
monitored intake and
output.

Encouraged patient to
eat fresh fruits such as
apples,
watermelons,and
singkamas.

Emphasized the use of
Oral Rehydration
Therapy

To replace
insensible fluid
loss.

For close
monitoring of
fluid loss.

Such fruits are
rich in water
which promotes
hydration


To meet fluid
demands of the
body.

At the end of 1 hour,
patient was able to
developed feelings of
relief from thirst.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
Masakit ang tiyan ko,
parang my tumutusok
na hindi ko
maintindihan as
verbalized by the
patient.

Objective:
-guarding behavior
(abdomen)
-facial grimace
-body weakness

Alteration in
Comfort: Abdominal
Pain r/t Traumatized
Nerve Endings 2 to
Bacterial Infection
as Manifested by
Inflamed Gastric
Linings

After 1 hour, the
patient will be able
to report that pain
relieves to
satisfactory level
with acceptable and
manageable side
effects and will have
decreased pain
scale from 7/10 to
4/10.

Positioned client to semi
fowlers position.





Encouraged patient to
engage in diversional
activities like talking
with her SO.

Increased fluid intake.




Provided comfort
measures such as back
rub.

Administered due meds.

To facilitate full lung
expansion and
promote adequate
oxygenation of body
cells which
alleviates pain.

To divert attention
from pain.



To facilitate
expectoration of
bacteria causing
pain.

To reduce anxiety
and promote
relaxation.

To relieve pain.

After 1, the patient
reported that pain
management relieves
pain to satisfactory level
with acceptable and
manageable side
effects and had
decreased pain scale
from 7/10 to 4/10. Goal
met.


ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective:
T= 39.6C
RR=28 cpm
Patient is warm to touch

Altered Body
Temperature:
Hyperthermia r/t
increased Pyrogens
in the Body 2 to
Bacterial Infection

After 2 hours, the
patients
temperature will
drop from 39.6C
to 37 C


Facilitated TSB.



Increased fluid intake.



Provided adequate
sleep and rest.

Provided a restful and
quiet environment.


Provided adequate
ventilation.

Monitored vital signs
especially temperature
for any changes.





Administered
Paracetamol as
ordered.

To facilitate cooling
action through
conduction.

To replace fluid loss
through
perspiration.

To facilitate fast
recovery from fever.

To facilitate
adequate resting
periods.

To facilitate comfort
in resting.

To determine the
effectiveness of the
nursing actions
rendered and to
monitor any
alteration in the vital
signs.

To decrease fever

After 2 hours, the
patients temperature
dropped from 39.6C
36.7C. Goal met.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
Gusto ko ng lumabas,
nababagot na ako dito
sa hospital,as
verbalized by the patient.

Objective:
-patient looks bored


Altered Stress
Coping r/t Inability
to Control
Stressor/s

After 2 hours, the
patient will
develop feelings
of comfort and
relief from
identified
stressor/s.

Encouraged patient to
perform diversional
activities such as telling
stories, reading, or
listening to music.

Applied therapeutic
communication.

Established rapport.






Talked to SO about
possible stressor/s.












To facilitate
control of
identified
stressor/s.


To facilitate
control of
stressor/s.
To facilitate
trust and
confidence
from patient
and be able to
bring out
stressor.
To facilitate the
identification of
stressor/s.

After 2 hours, the patient
verbalized and developed
feelings of relief and
emphasized control over
stressor/s. Goal met.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
Nanghihina na ako at di
ko masyadong
nagagawa mga gusto
kong gawin, as
verbalized by the patient.

Objective:
-pale
-facial grimace
-body weakness

Activity
Intolerance r/t
Body weakness

After 4 hours,the
patient will be
able to regain
strength and
verbalize
alleviation from
weakness.

Provided adequate
sleep and rest.


Provided quiet and
restful environment.


Provided adequate
ventilation.

Emphasized the
importance of CBR.


Maintained calm
attitude and
encouraged relaxation
techniques.

Watched out for
abnormal signs and
symptoms.

v/s taken and recorded.

For fast
regaining of
strength.

To facilitate
resting for the
patient.

For additional
comfort.

For fast
recovery from
weakness.

To reduce
anxiety.



To monitor for
possible
complications.

For monitoring






Goal partially met. After 4
hours, the patient
verbalized, Medyo
malakas na ako kaya lang
nararamdaman kong hindi
ko pa kayang bumangon.
Need for further rest is
recommended.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
nagtatae ako ng
matubig at limang
beses akong tumae sa
isang araw, as
verbalized by the
patient.

Objective:
-Loose watery stool

Diarrhea related to
malabsorption of
fluids and electrolytes
in the small and large
intestines

After 3 hours, the
patient will be able to
re-establish and
maintain normal
bowel functioning.

Positioned patient
in supine position

Maintained
BRAT diet


Ausculated
abdomen



Given IVF of
D5LRS

Administered
Hydrite Solution



To avoid increase
in gastrointestinal
motility
To allow for
bowel rest and to
prevent intestinal
overload
To determine
characteristics and
location of bowel
sounds

For fluid
replacement

For fluid and
electrolyte
replacement

Goal Partially met.
After 3 hours, the
patient re established
normal bowel
functioning.








ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
Di ako masyadong
makakain dahil
nagsusuka ako, as
verbalized by the
patient.

Objective:
-loss of weight from
42kgs to 41kgs

Risk for Imbalanced
Nutrition: Less than
body requirements
related to inadequate
food intake

At the end of the
shift, the patient will
verbalize
understanding on how
to regain and
maintain weight.

Emphasized
importance of small
frequent feeding
following the BRAT
diet during
hospitalization

Advised patient to
avoid gas forming
foods like spicy
foods, caffeinated
beverages, etc.

Provided information
regarding her
nutritional needs and
ways to meet these
needs

Advised patient to do
oral care before and
after meals

Promoted pleasant
and relaxing
environment while
eating

For easier
digestion of food





To avoid increase
in gastric motility




To provide
patient
understanding
and motivation
on her nutritional
needs
To stimulate
appetite



To enhance food
intake



Goal met. At the end
of the shift, the
patient verbalized
understanding on
regaining and
maintaining weight.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective:
-RR-28cpm
-Nasal flaring
Ineffective breathing
pattern related to pain
in the abdominal area
After 30 minutes, the
patients RR of
28cpm will be
decreased to its
normal state(16-
20cpm)
Positioned patient
in Semi-Fowler

Encouraged
patient to do deep
breathing
exercises

Encouraged
ambulation

Advised patient to
maintain good
posture

Encouraged
adequate rest
period between
activites
For better lung
expansion

For better lung
expansion



To promote
proper ventilation

To enhace
breathing pattern


To limit fatigue
Goal met. The
patients RR of
28cpm was decresed
to 19cpm.










ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective:
-poor skin turgor
Risk for impaired
skin integrity related
to poor skin turgor
After 2 hour, there
will be manifestations
of improved skin
turgor
Advised patient to
change position
every 2 hours

Encouraged
patient to apply
lotion as lubricant

Provided adequate
clothing or covers

Emphasized
importance of
adeaquate fluid
intake

Recommended
keeping nails
short
To avoid
ulceration


To promote good
skin turgor


To prevent
vasoconstriction

To maintain good
skin turgor



To reduce risk of
dermal injury
wneh itching is
present
Goal met. The patient
skin turgor was
improved.








ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective:
-dry cracked lips
-dry buccal mucosa
Impaired oral
mucous membrane
r/t fluid loss
secondary to
dehydration
After 3 hours, the
patient wil have a
moist buccal
mucosa and lips
>increased fliud
intake

>Encouraged daily
oral care(before
and after eating
especially at night)


>Suggested use of
sugarless gum or
candy like orbit gum

>To promote
rehydration

>To prevent acid
formation
associated with
retained food
particles

>to stimulate flow of
saliva and protect
mucous membrane
Goal partially met.
After 3 hours, the
patient has a moist
buccal mucosa and
lips