ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: (Risk for) fluid Entry of pathogens After series of Independent: After series of
Lagi akong volume deficit via the GIT will nursing - Monitor v/s -Tachycardia is nursing
dumudumi tapos related to diarrhea cause release of interventions, the present along with interventions, the
pag natapos na ako endotoxins that will client will be free varying degrees of client was free from
parang meron pa. increase peristalsis from dehydration hypotension. Fever dehydration and or
Iire naman ako pero and further result to and or hypovolemia increases hypovolemia
walang lumalabas diarrhea in order to metabolism and
eliminate exacerbates fluid
Objective: pathogens. loss
-frequent passing
out of stools (more -Monitor INO -Fluid replacement
than six times a day) needs are based on
-Pallor actual and ongoing
-Cold, clammy, dry fluid losses
skin
BP: 90/60
T: 37.0C -Encourage oral -To relieve thirst and
P: 124 rehydration if gag discomfort of dry
R:28 reflex, swallowing is mucous membrane
not compromised

Collaborative: -To monitor losses

-Encourage client to or
comply with lab hemoconcentration
tests such as CBC,
blood chemistry

Dependent: -To correct actual

-Administer IVF as and ongoing fluid
ordered losses

-To address
-Administer underlying cause of
medications diarrhea (E.
(metronidazole) as histolytica)
ordered
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Acute pain related Hyperperistalsis After series of Independent: After series of
Masakit yung tyan to disease process causes abdominal nursing -assess location and -To help determine nursing
ko cramping which is interventions, the severity of pain measures for interventions, the
painful. client will verbalize comfort client verbalized
Objective: absence or absence or
-facial grimace lessening of pain. -Promote -To determine lessening of pain.
-guarding behavior verbalization of underlying cause of
-irritability pain, whenever pain
-Pain scale of 7/10 present

-Advise client to -To promote muscle

apply warm relaxation
compress to the
abdomen

-Promote -To distract the

diversional activities clients attention for
his/her pain
Dependent:
-Administer pain -To aid in pain relief
medications as
prescribed (NSAIDs)

-Administer
medications for
underlying cause of
pain (metronidazole
for amoebiasis as
ordered)
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Deficient knowledge - After series of -Assess the clients -To know what After series of
Saan na nga po ulit regarding condition nursing level of language will be nursing
nakukuha ang related to interventions, the understanding/ appropriate to use interventions, the
amoeba? unfamiliarity with client will verbalize familiarity to terms while client verbalized
information understanding of communicating with understanding of
Objective: resources the disease process, the patient the disease process,
-frequency of its causes, its causes,
questions treatment and -Explain to the client -To make sure that treatment and
-statement of prevention the causes of the client is aware prevention
misunderstanding amoebiasis such as of the factors that
drinking may contribute to
unpasteurized milk, the disease process
tap water or spoiled
food

-Educate the client -To make the client

about antiprotozoal aware about the
drugs treatment
(metronidazole) are modalities of
effective for the amoebiasis
treatment of E.
histolytica

-Emphasize proper -To prevent further

hand washing and infections related to
food preparation improper food
sanitation and
preparation or
personal hygiene
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Hyperthermia A part of After series of Independent: After series of
Mainit po ako related to infection inflammatory nursing -Assess v/s, -to have baseline nursing
tsaka pakiramdam of the parotid process is having an interventions, the especially data interventions, the
ko glands increase in body client will be free temperature client was free from
temperature or from hyperthermia hyperthermia
Objective: hyperthermia. -Advise the client to -To alleviate fluid
-warm to touch increase fluid intake loss when theres an
-evident flushing of increase in body
the skin temperature
-facial grimace
-T- 38.6C -Loosen clients -To support heat
clothing evaporation

-Provide TSB -To help reduce

fever
Dependent:
-Administer anti- -To relieve the client
pyretics as from fever
prescribed
(paracetamol)

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Acute pain related Parotid glands After series of Independent: After series of
Sumasakit po yung to inflammation of become inflamed nursing -assess location and -To help determine nursing
panga ko the parotid glands and enlarged interventions, the severity of pain measures for interventions, the
therefore triggering client will verbalize comfort client verbalized
Objective: pain receptors. absence or absence or
-evident swelling lessening of pain. -Promote -To determine lessening of pain.
and tenderness of verbalization of underlying cause of
the mandibular area pain, whenever pain
of the face with an present
elevation in
temperature upon -Advise client to -To promote
palpation apply cold compress vasoconstriction
-facial grimace to the affected area that will help lessen
-guarding behavior the inflammation
-irritability and provide cooling
-Pain scale of 9/10 effect

-Promote -To distract the

diversional activities clients attention for
his/her pain
Dependent:
-Administer pain -To aid in pain relief
medications as
prescribed (NSAIDs)

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Deficient knowledge - After series of -Assess the clients -To know what After series of
Paano ko ba regarding condition nursing level of language will be nursing
nakuha ito nga ulit? related to interventions, the understanding/ appropriate to use interventions, the
(Mumps) unfamiliarity with client will verbalize familiarity to terms while client verbalized
information understanding of communicating with understanding of
Objective: resources the disease process, the patient the disease process,
-frequency of its causes, its causes,
questions treatment and -Explain to the client -To make sure that treatment and
-statement of prevention the process of the client is aware prevention
misunderstanding acquiring the of the factors that
infection (airborne) may contribute to
 the disease process

-Educate the client -To make the client

about the aware about the
supportive and treatment
symptomatic modalities of
management of mumps
mumps

-Emphasize proper -To prevent further

cough etiquette, airborne infections
handwashing and related to
infection control ineffective infection
measures control measures

-Emphasize possible -To make the client

complications of the conscious about the
disease (Orchitis) prognosis of the
disease

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Hyperthermia The body will try to After series of Independent: After series of
Mainit po related to infection compensate by nursing -Assess v/s, -to have baseline nursing
pakiramdam ko increasing body interventions, the especially data interventions, the
temperature and client will be free temperature client was free from
Objective: metabolism to kill from hyperthermia hyperthermia
-warm to touch the virus -Advise the client to -To alleviate fluid
-evident flushing of increase fluid intake loss when theres an
the skin increase in body
-facial grimace temperature
-T- 38.6C
 -Loosen clients -To support heat
clothing evaporation

-Provide TSB -To help reduce

fever
Dependent:
-Administer anti- -To relieve the client
pyretics as from fever
prescribed
(paracetamol)

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Fatigue related to Influenza causes After series of -Assess vital signs -To evaluate After series of
Nanghihina po disease state body malaise that nursing cardiopulmonary nursing
ako. alters the patients interventions, the response to activity interventions, the
activities client will report client reported
Objective: improved sense of -Establish realistic -To enhance improved sense of
-Lethargic energy activity goals with commitment to energy
-Drowsy client and promoting optimal
-Lack of energy encourage forward outcomes
-Disinterest in movement
surroundings
-Encourage rest -To conserve energy
periods

-Encourage -To promote energy

nutritionally dense,
easy to
prepare/consume
food
cough etiquette, airborne infections
handwashing and related to
infection control ineffective infection
measures control measures

-Emphasize -To make the client

prevention conscious about the
(Influenza Vaccine) prevention of the
disease