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Assessment Diagnosis Planning Implementation Evaluation

Case: amoebiasis Risk for deficient After a series of  Establish rapport through NPI At the end of the shirt
fluid volume nursing  Monitor intake and output, character the goals of the
Subjective:” madalas po akong related to intervention, the and amount of stools; estimate intervention will be seen
dumumi” as verbalized by the excessive losses client should in the patient as
through frequent insensible fluid losses. Measure urine
patients maintain evidence by:
diarrhea specific gravity and observe for
Objective: adequate fluid o Maintain
oliguria. (provides information about
o Restlessness volume as adequate fluid
over all fluid balance, renal function
o Irritability evidenced by volume as
good skin turgor and bowel disease control, as well as
o Facial grimace evidenced by
and balance guidelines for fluid replacement).
o Dry skin good skin turgor
intake and output  Assess vital signs (BP, Pulse,
o v/s taken as follows and balance
Temperature). (Hypotension including
Temp-37.4 intake and output
postural, tachycardia, fever can
Pulse- 79 o Vital signs within
indicate response to or reflect of fluid
RR- 19 normal range
loss)
BP- 110/70
 Observe for excessively dry skin and
mucous membranes, decreased skin
turgor
 Assess color and amount of urine. Report
urine output less than 30 ml/hr for 2
consecutive hours. (A normal urine output
is considered normal not less than
30ml/hour. Concentrated urine denotes
fluid deficit).
 Monitor and document temperature.
(Febrile states decrease body fluids by
perspiration and increased respiration.
This is known as insensible water loss).
 Monitor fluid status in relation to dietary
intake. (Most fluid comes into the body
through drinking, water in food, and water
formed by oxidation of foods. Verifying if
the patient is on a fluid restraint is
necessary).
 Weigh daily with same scale, and
preferably at the same time of day.
(Weight is the best assessment data for
possible fluid volume imbalance. An
increased in 2 lbs a week is consider
normal).
 Urge the patient to drink prescribed
amount of fluid. (Oral fluid replacement is
indicated for mild fluid deficit and is a cost-
effective method for replacement
treatment).
 Emphasize importance of oral hygiene.
(Fluid deficit can cause a dry, sticky
mouth. Attention to mouth care promotes
interest in drinking and reduces discomfort
of dry mucous membranes).
 Insert and IV catheter to have IV access.
(Parenteral fluid replacement is indicated
to prevent or treat hypovolemic
complications).
 Administer parenteral fluids as prescribed.
Consider the need for an IV fluid challenge
with immediate infusion of fluids for
patients with abnormal vital signs. (Fluids
are necessary to maintain hydration
status. Determination of the type and
amount of fluid to be replaced and infusion
rates will vary depending on clinical
status).
 Emphasize the relevance of maintaining
proper nutrition and hydration. (Increasing
the patient’s knowledge level will assist in
preventing and managing the problem).
Assessment Diagnosis Planning Implementation Evaluation

Case: amoebiasis Bloody stool due After a series of At the end of the shirt the
to infestation of nursing  Establish rapport through NPI goals of the intervention
Subjective:” may dugo po entamoeba intervention, the  Determine what is the cause of will be seen in the patient
kapag dumudumi ako” as histolytica on the color and the as evidence by:
blood in the stool, so we can
verbalized by the patients large intestine as characteristic of o Verbalize
evidence by classify if the blood is due to
Objective: stool are back to understanding about
black tarry stool bleeding in the UGI or bacterial
o Black tarry stool normal health instructions
infection
o Paleness given to prevent
 Evaluate medication taken that can
o Redness in perinea area food borne diseases
possibly lead to destruction of
o body weakness o laboratory results
organs may exacerbate bleeding.
o Blood pressure shown normal
 Monitor vital signs and note for
decreased from 120/80 values
sudden decrease in blood pressure
mmHg to 80/70mmHg o stool color and
due to excessive fluid loss in the
o Pulse rate is rapid from characteristics gone
body
68 bpm to 127 bpm normal
 Monitor laboratory data like fecal sis
o Vital signs: Blood
and blood chemistry to determine if
pressure from 80/70
there is a fluid and electrolyte loss
mmHg to 120/80
and bacterial infection.
mmHg
 Provide adequate diet rich in iron
o Vital signs: Pulse
such like green leafy vegetables as
rate from 127bpm to
it may help to supply iron in the
89 bpm
body.
 Administration of IV fluids as it will
serve as alternative fluid
replacement in the body
 Monitor stool consistency and
record findings as it will help to
provide baseline data

Health teaching
 Increase fluid intake as it will help
to replace fluid loss from the body
 provide adequate source of iron
like green leafy vegetables
 Encourage proper hygiene and
proper food handling
 Discourage eating raw foods, raw
foods like scallops, meats and
vegetables can harbor bacteria
coming from the market or certain
environment
Assessment Diagnosis Planning Implementation Evaluation

Case: amoebiasis Acute Pain related At the end of the shirt the goals of
After a series of nursing
to fissures on the  Establish rapport through NPI the intervention will be seen in
Subjective: “ang sakit rectal area as intervention, the client will  Review factors that aggravate or the patient as evidence by:
po ng puwet ko” as evidenced by alleviate pain. (May pinpoint  Pain is controlled as
verbalized by the facial grimace and  Report pain is precipitating or aggravating factors evidenced by scale of 3/10
patients pain scale of 7/10 (such as stressful events, food
relieved/controlled.  Able to sleep/rest
Objective:  Appear relaxed intolerance) or identify developing appropriately
 Facial grimace and able complications).
 Irritability to sleep/rest  Cleanse rectal area with mild soap and
appropriately. water or wipes after each stool and
 Fatigue
provide skin care (A&D ointment,
 Restless Sween ointment, karaya gel, Desitin,
 Pain scale of 7/10 petroleum jelly). (Protects skin from
bowel acids, preventing excoriation).
 Provide sitz bath as appropriate.
(Enhances cleanliness and comfort in
the presence of perianal irritation or
fissures).
 Encourage nonpharmacologic
measures. (to relieve pain)
 Increase fluid intake (to replace fluid
loss)
Assessment Diagnosis Planning Implementation Evaluation

Case: amoebiasis Acute abdominal After a series of At the end of the shift the goals of the
pain due to nursing  Establish rapport through NPI intervention will be seen in the
Subjective: “subrang abdominal intervention, the  Determine what causes pain as it will help patient as evidence by:
sakit po ng tiyan ko” as distention related to pain decreased  Verbalize understanding about
to identify what specific conditions is
verbalized by the patients infestation of from 8/10 to 5/10 client’s diet restrictions
entamoeba related
Objective:  The pain decreases from 8/10
histolytica as  Use pain rating scale appropriate for
 Irritability to 5/10
manifested by a age/cognition (e.g. 0-10 scale, facial
 pain scale of 8/10 pain scale of 8/10  Abdominal tenderness is
expression)
 restlessness
 Accepts client description of pain. relieved
 diaphoresis Acknowledge the pain experience and  Pulse rate return to normal from
 blood pressure convey acceptance of client response to 110 to 69bpm
increase from 120/80 pain. (Pain is subjective experience and  Blood pressure is normal
mmHg to 140/90 cannot be felt by others)
mmHg  Note when pain occurs to medicate
 Pulse rate increase prophylactically as appropriate
from 67 bpm to 110  Determine if the client use analgesia
bpm without physician’s order
 facial grimacing  Assess abdominal tenderness
 Monitor and record pain assessment result
as it will help to provide baseline data
 Administer analgesia as ordered by the
physician
 Provide comfort measures like touch,
repositioning, use of heat or cold packs,
quiet environment and calm activities to
promote non pharmacological pain
management
 Instruct or encourage use of relaxation
techniques such as focused breathing,
imaging to distract attention and reduce
tension
 Encourage verbalization of feelings about
the pain

Health teachings:

 Encourage adequate rest periods to


prevent fatigue
 encourage the client to change lifestyle it
may help on certain problem
Assessment Diagnosis Planning Implementation Evaluation

Case: amoebiasis Imbalanced After a At the end of the shift the goals of
nutrition less than series of  Establish rapport through NPI the intervention will be seen in the
Subjective: “I have loss body requirements nursing  Determine client’s ability to chew, swallow and patient as evidence by:
so much appetite” as related to inability intervention,  The clients gradually gain
taste food. Evaluate teeth and gums for poor oral
verbalized by the patients to ingest adequate the client weight.
nutrient as health and note denture fit as indicated (all
Objective: demonstrate  Verbalize understanding about
manifested by loss factors that can affect ingestion or digestion of
 Fatigue progressive the importance of adequate
of appetite nutrients.
 Weakness weight gain
toward  Assess weight, measures/calculate body fat and nutrition
 Body Wasting muscle mass via triceps skin fold and midarm  Skin is warm to touch
goals
 Paleness muscle circumference or other anthropometric  Demonstrate a behavior to
 Restlessness measurements to establish baseline parameters increase daily food intake to re
 Skin is cold to touch  Observe for absence of subcutaneous fats, loss store the body
of hair, fissuring of nails, delayed healing, gum
bleeding, swollen abdomen that indicate protein
energy malnutrition
 Note age, body build, strength, activity/rest level
it helps to determine nutritional needs
 Evaluate total daily food intake. Obtain diary of
calorie intake, patterns and times of eating to
reveal possible cause of malnutrition/changes
that could be made in client’s intake
 Assist in treating underlying causative factors
 Consult dietitian as indicated to implement
interdisciplinary team management
 Administer pharmaceutical agents as indicated
such as vitamins and mineral supplements
 Promote pleasant, relaxing environment including
socialization to enhance intake
 Limit fiber if indicated because it may lead to
early satiety
 Promote adequate fluid intake
 Administer iv fluid as prescribed to restore the
fluid loss in the body

Health teaching:

 Emphasize the importance of well balanced


diet, nutritious intake. Provide information
regarding individual nutritional needs and ways
to meet the need
 Weight at regular intervals and document the
results to monitor the effectiveness of dietary
plan.
 Develop regular exercise and stress reduction
program
Assessment Diagnosis Planning Implementation Evaluation

Case: AIDS Fatigue may be After a series At the end of the shift the goals
related to of nursing  Establish rapport through NPI of the intervention will be seen in
Subjective: “I get easily decrease intervention,  Identify presence of physical or psychological the patient as evidence by:
feel weak and very tired” metabolic the client will  Improved the energy level
conditions such as pregnancy, infectious processes,
energy
as verbalized by the restore or hepatitis etc.  Gradually return or
patients production as improved the
evidenced by  Review medication use. Certain medications including performs the activity of
Objective: sense of daily living
lethargy and perceptions, over the counter, herbal supplements and
 Fatigue energy and
restlessness substances are known to cause exacerbate fatigue  Demonstrate a behavior of
 Weakness able to
perform  Ascertain client’s belief about what is causing fatigue proper sleep pattern and
 Paleness rest
activities of  Assess vital signs to evaluate fluid status and
 Poor appetite  Vital signs are normal
daily living at cardiopulmonary response to activity
 Restlessness level of ability  Determine presence of sleep disturbances. Fatigue can
 Lethargy
be consequence of sleep deprivation
 drowsy
 Note recent lifestyle changes, including conflicts,
 Temp.37c maturational issues and developmental issues
 Pulse: 120bpm
 Obtain client descriptions of fatigue to assist in
 RR: 16 evaluating on client’s lifestyle
 Ask the client to rate fatigue (1-10 scale) and its effects
on ability to participate in desired activities
 Instruct in methods to conserve energy like sit instead
of stand during daily care.
 Keep bed in low position and assist with ambulation as
indicated
 Avoid or limit exposure to temperature and humidity
extremes which can negatively impact energy level.
 Provide diversional activities. Avoid over stimulation or
under stimulation. Participating in pleasurable activities
can refocus energy and diminish feeling of
unhappiness, sluggishness, and worthlessness that can
accompany fatigue
 Discuss routines to promote restful sleep
 Encourage nutritionally dense, easy to prepare foods
and to avoid caffeine and high sugar foods or drinks to
promote energy
 Implement stress management skills of visualization,
relaxation and biofeedback when appropriate
 Refer to comprehensive rehabilitation program, physical
therapy for programmed daily exercises and activities to
improve stamina, strength and muscle tone and to
enhances sense of well being
 Promote over all health measures like adequate fluid
intake, appropriate vitamins and iron supplement
Assessment Diagnosis Planning Implementation Evaluation

Case: AIDS Imbalanced Maintain At the end of the shift the


nutrition related weight or  Establish rapport through NPI goals of the intervention will
Subjective: “Hindi ako to inability to display weight  Assess patient ability to chew, taste and swallow be seen in the patient as
makakain ng maayos” as ingest because gain toward evidence by:
(lesions of the mouth, throat and esophagus and metallic
verbalized by the patients of mouth sores desired goal  Maintain weight
as evidenced or other taste changes may cause dysphagia limiting
Objective: and be free
patient’s ability to ingest food and reducing desire to eat)  Free from signs of
by poor appetite
 Fatigue from signs of malnutrion
 Auscultate bowel sounds. (Hyper motility of intestinal
 Weakness malnutrition
tract is common and is associated with vomiting
 Paleness and diarrhea, which may affect choice of diet/route.
 Poor appetite Lactose intolerance and malabsorption contribute to
 Restlessness diarrhea and may necessitate change in diet or
 Lethargy supplemental formula).
 Sores in the mouth  Weigh as indicated. Evaluate weight in terms of
premorbid weight. Compare serial weight and
anthropometric measurement. (Indicator of nutritional
adequacy of intake. Because of depressed immunity,
some blood tests normally used for testing nutritional
status are not useful).
 Note drug side effects. (Medications used can have side
effects affecting nutrition. ZDV can cause altered taste,
nausea and vomiting; Bactrim can cause
anorexia, glucose intolerance and glossitis; Pentam can
cause altered taste and smell; Protease inhibitors can
cause elevated lipids, blood sugar increase due
to insulin resistance
 Plan diet with patient suggesting foods from home if
appropriate. Provide small, frequent meals and snacks
of nutritionally dense foods and non acidic foods and
beverages, with choice of foods palatable to patient.
Encourage high-calorie and nutritious foods, some of
which may be considered appetite stimulants. Note time
of day when appetite is best, and try to serve larger meal
at that time.
 Limit foods that induce nausea or vomiting or are poorly
tolerated by patient because of mouth sores
or dysphagia. Avoid serving very hot liquids and foods.
Serve foods that are easy to swallow like eggs, ice
cream, cooked vegetables.
 Schedule medications between meals (if tolerated) and
limit fluid intake with meals, unless fluid has nutritional
value.
 Encourage as much physical activity as possible. (May
improve appetite and general feelings of well-being).
 Provide frequent mouth care, observing secretion
precautions. Avoid alcohol-containing mouthwashes.it
may enhance appetite and provide comfort
 Provide rest period before meals. Avoid stressful
procedures close to mealtime. (Minimizes fatigue;
increases energy available for work of eating and
reduces chances of nausea or vomiting food).
 Encourage patient to sit up for meals. (Facilitates
swallowing and reduces risk of aspiration).
Assessment Diagnosis Planning Implementation Evaluation

Case: AIDS Impaired skin At the end of the shift the


After a series
integrity due to  Establish rapport through NPI goals of the intervention will be
Subjective: “I have immunologic of nursing  Assess skin daily. Note color, turgor, circulation, and seen in the patient as
lesions on my buttocks” deficit as sensation. Describe and measure lesions and observe evidence by:
evidenced by intervention,
as verbalized by the changes. Take photographs if necessary.  Demonstrate behaviors
patients skin lesions on the client will  Maintain and instruct in good skin hygiene: wash that promote wound
Objective: the buttocks thoroughly, pat dry carefully, and gently massage with
Be free of or healing
 Fatigue lotion or appropriate cream. Maintain a clean, dry skin
 Verbalize understanding
 Weakness display provides a barrier in the infection.
on the importance of
 Reposition frequently. Use turn sheet as needed.
 Paleness improvement good hygiene
Encourage periodic weight shifts. Protect bony
 Poor appetite prominences with pillows, heel and elbow pads,  Display improvements on
in
 Restlessness sheepskin. Reduces stress on pressure points, improves the skin lesions
 Lesions on the wound/lesion blood flow to tissues, and promotes healing
buttocks  Maintain clean, dry, wrinkle-free linen, preferably soft
healing. And
 Temperature increase cotton fabric. Skin friction caused by wet or wrinkled or
demonstrates rough sheets leads to irritation.
from 37c to 38c
 Encourage ambulation as tolerated. Decreases pressure
behaviors to on skin from prolonged bedrest.
promote  File nails regularly. Long and rough nails increase risk of
dermal damage.
healing  Provide foam, flotation, alternate pressure mattress or
bed. Reduces pressure on skin, tissue, and lesions,
decreasing tissue ischemia.
 Obtain cultures of open skin lesions. Identifies pathogens
and appropriate treatment choices
 Apply and administer medications as indicated. Used in
treatment of skin lesions. Use of agents such as Prederm
spray can stimulate circulation, enhancing healing
process. When multidose ointments are used, care must
be taken to avoid cross-contamination.
 Cover ulcerated KS lesions with wet to wet dressings or
antibiotic ointment and non-stick dressing as indicated.
Protects ulcerated areas from contamination and promote
healing
 Refer to physical therapy for regular exercise and activity
program. Promotes improved muscle tone and skin
health.
Assessment Diagnosis Planning Implementation Evaluation

Case: AIDS Social isolation At the end of the shift the


After a
related to  Establish rapport through NPI goals of the intervention will
Subjective: “I feel alone inadequate series of  Ascertain patient’s perception of situation (isolation may be be seen in the patient as
because of my disease” personal evidence by:
nursing partly self imposed because patient fears rejection)
as verbalized by the support as  Demonstrate a behavior
evidenced by  Spend time talking with patient during and between care
patients intervention, that will identify
expressed activities. Be supportive, allowing for verbalization. Treat
Objective: supportive individual.
feeling of a the client with dignity and regard for patient’s feelings (patient may
 Fatigue  Demonstrate a behavior
loneliness experience physical isolation as result of current medical
 Weakness imposed by will identify of participating in
status and some degree of social isolation secondary to
 Paleness others, feelings supportive activities
diagnosis of aids
 Poor appetite of rejection
individual  Limit use of mask, gown and gloves when possible and
 Restlessness when talking to patient (reduces patient sense of physical
 Irritability and
isolation, which may enhance self esteem and decrease
 Avoidance of participate negative behaviors)
socialization  Identify supports system available patients, including
in activities
presence of relationship with immediate and extended
at level of family to diminish feelings of loneliness and rejection
ability  Explain isolation precaution and procedures to patient and
to the family it helps the patient to understand reasons for
procedure and provide feeling of inclusion in what is
happening
 Encourage open visitation as able, telephone contacts, and
social activities within tolerated level it fosters a feelings of
belonging
 Develop a plan with patient look at available resources;
support healthy behaviors, help patient problem solve
solution to short term or imposed isolation (having a plan
promotes a sense of control over her own life and give her
something to look forward)
 Be alert to verbal or non verbal cues, withdrawal,
statements of despair, sense of loneliness. Ask patient if
thoughts of suicide are being entertained. (indicators of
despair and suicidal ideation are often present, when this
cues are acknowledging by the caregiver, patients are
usually willing to talk about thoughts of suicide and sense
of isolation and hopelessness
Assessment Diagnosis Planning Implementation/Rationale Evaluation
Case: AIDS fluid volume At the end of the shift the
After a series
deficit due to  Establish rapport through NPI goals of the intervention will
Subjective: “I am overly excessive of nursing  Monitor vital signs. note hypotension including postural be seen in the patient as
sweating and I have a sweating and evidence by:
intervention, changes it indicates circulating fluid volume
diarrhea” as verbalized by diarrhea as  Vital signs within normal
evidenced by  Note temperature elevation and duration of febrile
the patients the client will limit
dry mucous episode. Administer tepid sponge baths as indicated.
Objective:  Urinary output is
membranes maintain Keep clothing and linens dry. Maintain comfortable
 Fatigue adequate
and poor skin environmental temperature.
 Weakness turgor hydration as
 Good skin turgor
 Assist skin turgor, mucous membranes, and thirst it is
 Paleness evidenced by  Moist mucous
indirect indicator of fluid status
 Poor appetite membranes
moist  Measure urinary output and specific gravity. Measures
 Restlessness
and estimate amount of diarrheal loss. Note insensible
 dry mucous mucous
losses (increase specific gravity and decrease urinary
membranes membranes, output reflects altered renal perfusion and circulating
 poor skin turgor volume. Monitoring fluid balances is difficult in the
good skin
 thirst presence of excessive GI and insensible losses)
 urinary output of 9ml turgor, stable
 Weigh as indicated (fluid losses associated with diarrhea
 sunken eyes vital signs, can quickly create a crisis and become life threatening)
 pulse is increases  Monitor oral intake and encourage fluids of at least 2500
individually
from 72bpm to ml/ day it reduces thirst and keeps mucous membranes
120bpm adequate moist
urinary  Make fluids easily accessible to patient, use fluids that
are tolerable to patient and that replace needed
output
electrolytes (enhances intake certain fluids may be too
painful to consume like acidic juices because of mouth
sores.
 Eliminates food potentiating diarrhea (may help reduce
diarrhea. Use of lactose free products helps control
diarrhea in the lactose tolerant patient
 Encourage use of live culture yogurt (antibiotic therapies
disrupt normal bowel flora balance, leading to diarrhea.
Must be taken 2 hours before or after antibiotic to prevent
inactivation of live culture
 Administer fluids and electrolytes via feeding tube and IV
as appropriate. (may be necessary to support circulating
volume, especially if oral intake is inadequate nausea and
vomiting persist.
 Monitor laboratory studies as indicated. Serum or urine
electrolytes. (alerts to possible electrolyte disturbances
and determines replacement needs. Evaluate renal
perfusion and function).
 Maintain hypothermia blanket if used (may be necessary
when other measures fail to reduce excessive fever)
Assessment Diagnosis Planning Implementation/Rationale Evaluation

Case: pulmonary Ineffective After a series of At the end of the shift the
tuberculosis airway nursing  Establish rapport through NPI goals of the intervention will be
clearance intervention, the  Assess respiratory function noting breath sounds, rate, seen in the patient as
Subjective: “nahihirapan related to thick, client will: rhythm, and depth, and use of accessory muscles. evidence by:
akong huminga” as viscous or  Maintain a (Diminished breath sounds may reflect atelectasis.  Clients respiratory rate is
verbalized by the patients bloody patent Rhonchi, wheezes indicate accumulation of secretions within normal range
Objective: secretions as and inability to clear airways that may lead to use of
airway RR:18bpm
evidenced by
 Fatigue  Expectorate accessory muscles and increased work of breathing).
 Secretions decreased
dyspnea  Note ability to expectorate mucus and cough
 Weakness secretions  Clients restlessness was
effectively; document character, amount of sputum,
 Poor appetite without
alleviated and remain
assistance presence of hemoptysis. (Expectoration may be difficult
 Restlessness when secretions are very thick as a result of infection calm
 Demonstrate
 Cough and/or inadequate hydration).  Temperature is within
a behavior
 Bloody sputum  Place patient in semi or High-Fowler’s position. Assist normal range
to maintain patient with coughing and deep-
 Chest pain patent  Clients expectorate
 Dyspnea breathing exercises.(Positioning helps maximize lung
airway secretions without
expansion and decreases respiratory effort. Maximal
 Abnormal breath clearance. ventilation may open atelectatic areas and promote assistance
sounds: wet crackles movement of secretions into larger airways for
 Temperature expectoration).
increases from 36c to  Clear secretions from mouth and trachea; suction as
37.5c necessary.( Prevents obstruction and aspiration.
 BP:80/60 Suctioning may be necessary if patient is unable to
expectorate secretions).
 RR:26 bpm
 Maintain fluid intake of at least 2500 mL/day unless
 PR:75bpm contraindicated. (High fluid intake helps thin secretions,
making them easier to expectorate).
 Humidify inspired air and oxygen. (Prevents drying of
mucous membranes and helps thin secretions).
 Administer medications as indicated:
o Mucolytic agent (acetyl cysteine) it
reduces the thickness of pulmonary
secretions.
o Bronchodilators (oxtriphylline) it increases
lumen size of the tracheobronchial tree,
thus decreasing resistance to airflow and
improving oxygen delivery.
o Corticosteroid may be useful in presence
of extensive involvement with profound
hypoxemia and when inflammatory
response is life threatening
 Be prepared for/assist with emergency intubation.(
intubation may be necessary in rare cases of
bronchogenic TB accompanied by laryngeal edema
or acute pulmonary bleeding).
Assessment Diagnosis Planning Implementation Evaluation

Case: pulmonary Imbalanced After a series of nursing At the end of the shift the
tuberculosis nutrition less intervention, the client will:  Establish rapport through NPI goals of the intervention will
than body  Demonstrate  Document patient’s nutritional status on be seen in the patient as
Subjective: “I have requirements progressive weight admission, noting skin turgor, current weight and evidence by:
loss so much weight” related to gain toward goal with degree of weight loss, integrity of oral mucosa,  Demonstrate a
as verbalized by the frequent normalization of ability or inability to swallow, presence of bowel behavior to change
patients cough/sputum laboratory values and tones, history of nausea and vomiting or diarrhea.(
production, lifestyle and to regain
Objective: be free of signs of Useful in defining degree or extent of problem and
dyspnea as weight
 Fatigue malnutrition. appropriate choice of interventions).
evidenced by  Ascertain patient’s usual dietary pattern. Include in  Vital signs within
 Weakness weight 10%-  Initiate
selection of food. (Helpful in identifying specific normal limit
 Poor appetite 20% below behaviors/lifestyle
changes to regain needs and strengths. Consideration of individual
 Restlessness ideal for frame
and/or to maintain preferences may improve dietary intake).
 Cough and height and
appropriate weight.  Monitor I&O and weight periodically. (Useful in
poor muscle
 Body wasting tone
measuring effectiveness of nutritional and fluid
 Dyspnea support.
 Investigate anorexia and nausea and vomiting,
 Poor muscle tone
and note possible correlation to medications.
 RR:25Bbpm Monitor frequency, volume, consistency of stools.
(May affect dietary choices and identify areas for
problem solving to enhance intake and utilization
of nutrients).
 Encourage and provide for frequent rest periods.(
Helps conserve energy, especially when
metabolic requirements are increased by fever).
 Provide oral care before and after respiratory
treatments. (Reduces bad taste left from sputum
or medications used for respiratory treatments that
can stimulate the vomiting center).
 Encourage small, frequent meals with foods high
in protein and carbohydrates. (Maximizes nutrient
intake without undue fatigue/energy expenditure
from eating large meals, and reduces gastric
irritation).

 Encourage SO to bring foods from home and to


share meals with patient unless contraindicated.
(Creates a more normal social environment during
mealtime, and helps meet personal, cultural
preferences).

 Refer to dietitian for adjustments in dietary


composition. (Provides assistance in planning a
diet with nutrients adequate to meet patient’s
metabolic requirements, dietary preferences, and
financial resources post discharge).

 Consult with respiratory therapy to schedule


treatments 1–2 hr before or after meals. (May help
reduce the incidence of nausea and vomiting
associated with medications or the effects of
respiratory treatments on a full stomach).

 Monitor laboratory studies: BUN, serum protein,


and prealbumin, albumin. (Low values reflect
malnutrition and indicate need for intervention and
change in therapeutic regimen).

 Administer antipyretics as appropriate. (Fever


increases metabolic needs and therefore calorie
consumption)
Assessment Diagnosis Planning Implementation/Rationale Evaluation

Case: pulmonary Deficient After a series of nursing At the end of the shift the
tuberculosis knowledge intervention, the client will:  Establish rapport through NPI goals of the intervention will
related to  Verbalize  Assess patient’s ability to learn. Note level of fear, be seen in the patient as
Subjective: “my inaccurate understanding of concern, fatigue, participation level; best evidence by:
disease is a information disease environment in which patient can learn; how much  Verbalize
punishment from god it presented as process/prognosis and content; best media and language; who should be understanding of the
cannot be cured” as evidenced by prevention. included.( Learning depends on emotional and disease process and its
verbalized by the
expressed  Initiate physical readiness and is achieved at an
misconceptions prevention
patients behaviors/lifestyle individual pace).
about the changes to improve  Provide instruction and specific written information  Demonstrate a
Objective: health status general well-being and for patient to refer to schedule for medications and behavior to change
 Fatigue
reduce risk of follow-up sputum testing for documenting lifestyle and improve
 Weakness reactivation of TB. response to therapy. (Written information relieves general well being
 Poor appetite  Identify symptoms patient of the burden of having to remember large  Verbalize the
 Restlessness requiring amounts of information. Repetition strengthens symptoms that require
 Cough evaluation/intervention. learning).
 Verbalize intervention
 Body wasting  Encourage patient and SO to verbalize fears and
understanding of concerns. Answer questions factually. Note  Verbalize
 Dyspnea therapeutic regimen understanding of
prolonged use of denial.( Provides opportunity to
 Poor muscle tone and rationale for correct misconceptions and alleviate anxiety. therapeutic regimen
 irritability actions. Inadequate finances or prolonged denial may and rationale for
affect coping and managing the tasks necessary actions
to regain health).
 Identify symptoms that should be reported to
healthcare provider: hemoptysis, chest pain, fever,
difficulty breathing, hearing loss, vertigo.( May
indicate progression or reactivation of disease or
side effects of medications, requiring further
evaluation.
 Emphasize the importance of maintaining high-
protein and carbohydrate diet and adequate fluid
intake. (Meeting metabolic needs helps minimize
fatigue and promote recovery. Fluids aid in
liquefying or expectorating secretions).

 Explain medication dosage, frequency of


administration, expected action, and the reason
for long treatment period. Review potential
interactions with other drugs and substances.
(Enhances cooperation with therapeutic regimen
and may prevent patient from discontinuing
medication before cure is truly affected. Directly
observed therapy (DOT) is the treatment of choice
when patient is unable or unwilling to take
medications as prescribed).

 Stress need to abstain from alcohol while on INH.(


Combination of INH and alcohol has been linked
with increased incidence of hepatitis.

 Refer for eye examination after starting and then


monthly while taking ethambutol.( Major side
effect is reduced visual acuity; initial sign may be
decreased ability to perceive green).

 Evaluate job-related risk factors, working in


foundry or rock quarry, sandblasting. (Excessive
exposure to silicone dust enhances risk of
silicosis, which may negatively affect respiratory
function and cause bronchitis).
 Encourage abstaining from smoking.( Although
smoking does not stimulate recurrence of TB, it
does increase the likelihood of respiratory
dysfunction or bronchitis.

 Review how TB is transmitted (primarily by


inhalation of airborne organisms, but may also
spread through stools or urine if infection is
present in these systems) and hazards of
reactivation. (Knowledge may reduce risk of
transmission/reactivation. Complications
associated with reactivation include cavitation,
abscess formation, destructive emphysema,
spontaneous pneumothorax, diffuse interstitial
fibrosis, serous effusion, empyema,
bronchiectasis, hemoptysis, GI ulceration,
Broncho pleural fistula, tuberculous laryngitis, and
miliary spread).
Assessment Diagnosis Planning Implementation/Rationale Evaluation

Case: pulmonary Risk for After a series of nursing At the end of the shift
tuberculosis Impaired gas intervention, the client will:  Establish rapport through NPI the goals of the
exchange  Report absence  Assess for dyspnea (using 0–10 scale), tachypnea, intervention will be
Subjective: “I have related to of/decreased dyspnea. abnormal or diminished breath sounds, increased seen in the patient as
difficulty in breathing” Thick, viscous  Demonstrate improved respiratory effort, limited chest wall expansion, evidence by:
as verbalized by the secretions ventilation and and fatigue.( Pulmonary TB can cause a wide range  Decreased
patients adequate oxygenation of effects in the lungs, ranging from a small patch of dyspnea
Objective: of tissues by ABGs bronchopneumonia to diffuse intense inflammation,  Demonstrate
 Fatigue within acceptable cereous necrosis, pleural effusion, and extensive
ranges. fibrosis. Respiratory effects can range from mild improved
 Weakness ventilation and
 Be free of symptoms of dyspnea to profound respiratory distress. Use of a
 Poor appetite respiratory distress. scale to evaluate dyspnea helps clarify degree of adequate
 Restlessness difficulty and changes in condition). oxygenation
 Productive Cough  Evaluate change in level of mentation. Note cyanosis  Vital signs within
 Body wasting and/or change in skin color, including mucous normal limit.
membranes and nail beds.( Accumulation of
 Dyspnea  Free from
secretions and/or airway compromise can impair
 Poor muscle tone oxygenation of vital organs and tissues). symptoms of
 RR- 36bpm  Demonstrate and encourage pursed-lip breathing respiratory
 Diminished breath during exhalation, especially for patients with fibrosis distress
sounds or parenchymal destruction. (Creates resistance
 O2 sat. - 86% against outflowing air to prevent collapse or
narrowing of the airways, thereby helping distribute
air throughout the lungs and relieve or reduce
shortness of breath).
 Promote bedrest or limit activity and assist with self-
care activities as necessary.( Reducing oxygen
consumption and demand during periods of
respiratory compromise may reduce severity of
symptoms).
 Monitor serial ABGs and pulse oximetry. (Decreased
oxygen content (PaO2) and/or saturation or
increased PaCO2 indicate need for intervention or
change in therapeutic regimen).
 Provide supplemental oxygen as appropriate. (Aids
in correcting the hypoxemia that may occur
secondary to decreased ventilation/diminished
alveolar lung surface)
Assessment Diagnosis Planning Implementation/Rationale Evaluation

Case: Pneumonia Hyperthermia After a series of nursing At the end of the shift
Subjective: “I feel hot related to intervention, the client will:  Establish rapport through NPI the goals of the
“as verbalized by the Infection as  maintains body  Monitor the patient’s HR, RR, and especially the intervention will be
patients evidenced by temperature within tympanic or rectal temperature. (HR and RR seen in the patient as
Objective: elevated body normal range. increase as hyperthermia progresses. Tympanic or evidence by:
 Fatigue temperature  maintains RR and HR rectal temperature gives a more accurate indication  Temperature
 Hot, flushed skin within normal limits. of core temperature). within normal
 Temp- 38.5
.  Determine the patient’s age and weight. (Extremes range.
of age or weight increase the risk for the inability to
 RR- 36bpm  RR and HR within
control body temperature).
 HR- 122bpm  Monitor fluid intake and urine output. If the patient is normal limits
unconscious, central venous pressure or pulmonary
artery pressure should be measured to monitor fluid
status. (Fluid resuscitation may be required to
correct dehydration. The patient who is significantly
dehydrated is no longer able to sweat, which is
necessary for evaporative cooling).
 Review serum electrolytes, especially serum
sodium.( Sodium losses occur with profuse
sweating and accidental hyperthermia).
 Adjust and monitor environmental factors like room
temperature and bed linens as indicated. (Room
temperature may be accustomed to near normal
body temperature and blankets and linens may be
adjusted as indicated to regulate temperature of the
patient).
 Eliminate excess clothing and covers. (Exposing
skin to room air decreases warmth and increases
evaporative cooling).
 Give antipyretic medications as prescribed.
(Antipyretic medications lower body temperature by
blocking the synthesis of prostaglandins that act in
the hypothalamus)
 Ready oxygen therapy for extreme cases.(
Hyperthermia increases the metabolic demand for
oxygen).
Assessment Diagnosis Planning Implementation/Rationale Evaluation

Case: Pneumonia Acute Pain After a series of nursing At the end of the shift the
Subjective: “subrang related to intervention, the client will:  Establish rapport through NPI goals of the intervention will
sakit po ng dibdib ko Persistent  Patient will verbalize  Assess pain characteristics: sharp, constant, be seen in the patient as
“as verbalized by the coughing as relief/control of pain at stabbing. Investigate changes in character, location, evidence by:
patients evidenced by level less than 3 to 4 or intensity of pain. Assess reports of pain with  Verbalization of pain
Objective: Chest pain of using a rating scale of 0 breathing or coughing. (Chest pain, usually present control from 8/10 to
7/10 to 10.
 Self-focused to some degree with pneumonia, may also herald 4/10
 Moaning,  Patient will demonstrate the onset of complications of pneumonia, such as
relaxed manner,  Demonstrate relaxed
restlessness pericarditis and endocarditis).
resting/sleeping and  manner,
 Facial mask, Monitor vital signs. (Changes in heart rate or BP
engaging in activity may indicate that patient is experiencing pain, resting/sleeping and
distraction
behaviors appropriately. especially when other reasons for changes in vital engaging in activity
 Irritability  Patient will verbalize signs have been ruled out). appropriately
 Tachycardia understanding of no  Provide comfort measures: back rubs, position  Verbalize
pharmacological changes, quite music, massage. Encourage use of
 BP- 130/90 understanding on the
interventions for pain relaxation and/or breathing exercises. (Non-
 Tachypnea importance of non
relief. analgesic measures administered with a gentle
 Chest pain7/10 pharmacologic
touch can lessen discomfort and augment
therapeutic effects of analgesics. Patient interventions to
involvement in pain control measures promotes relieve pain.
independence and enhances sense of well-being).
 Offer frequent oral hygiene. (Mouth breathing and
oxygen therapy can irritate and dry out mucous
membranes, potentiating general discomfort).
 Instruct and assist patient in chest splinting
techniques during coughing episodes. (Aids in
control of chest discomfort while enhancing the
effectiveness of cough effort).
 Administer antitussives as indicated. Do not
suppress a productive cough; moderate amounts of
analgesics are used to relieve pleuritic pain. (These
medications may be used to suppress non-
productive cough or reduce excess mucus, thereby
enhancing general comfort. Coughing is necessary
to mobilize secretions and suppressing cough will
cause retained secretions and delay resolution of
pneumonia).
 Administer analgesics as prescribed. Encourage
patient to take analgesics before discomfort
becomes severe. (Medications allow for pain relief
and the ability to deep breath and cough.
Analgesics help prevent peak periods of pain).
Assessment Diagnosis Planning Implementation/Rationale Evaluation

Case: Pneumonia Activity After a series of nursing At the end of the shift
Subjective: Intolerance intervention, the client will:  Establish rapport through NPI the goals of the
“nanghihina ako “as related to  Report/demonstrate a  Determine patient’s response to activity. Note intervention will be
verbalized by the General measurable increase in reports of dyspnea, increased weakness and seen in the patient as
patients weakness as tolerance to activity with fatigue, changes in vital signs during and after evidence by:
Objective: evidenced by absence of dyspnea activities. (Establishes patient’s capabilities and  Vital signs within
tachycardia in and excessive fatigue,
 Fatigue needs and facilitates choice of interventions). normal range
response to and vital signs within 
 Restless activity.
Provide a quiet environment and limit visitors during  Demonstrate a
patient’s acceptable acute phase as indicated. Encourage use
 worsening of measurable
range. of stress management and diversional activities as
pallor/cyanosis tolerance to
 weakness appropriate.( Reduces stress and excess
stimulation, promoting rest) activity with the
 dyspnea
 Explain importance of rest in treatment plan and absence of
 Tachycardia in
necessity for balancing activities with rest. (Bedrest dyspnea
response to is maintained during acute phase to decrease
activity metabolic demands, thus conserving energy for
 RR- 28bpm healing. Activity restrictions thereafter are
 HR- 123bpm determined by individual patient response to activity
and resolution of respiratory insufficiency).
 Pace activity for patients with reduced activity.
(Effective coughing may exhaust an already
compromised patient. Fatigue may be a contributing
factor to ineffective coughing).
 Assist patient to assume comfortable position
for rest and sleep. (Patient may be comfortable with
head of bed elevated, sleeping in a chair, or leaning
forward on over bed table with pillow support).
 Assist with self-care activities as necessary.
Provide for progressive increase in activities during
recovery phase. and demand. (Minimizes
exhaustion and helps balance oxygen supply and
demand).
Assessment Diagnosis Planning Implementation/Rationale Evaluation

Case: Pneumonia Ineffective After a series of nursing At the end of the shift
Subjective: Breathing intervention, the client will:  Establish rapport through NPI the goals of the
“nahihirapan akong Pattern related  Patient  Assess and record respiratory rate and depth at least intervention will be seen
huminga “as verbalized to Decreased maintains an every 4 hours. (The average rate of respiration for in the patient as
by the patients lung expansion effective breathing adults is 10 to 20 breaths per minute. It is important to evidence by:
Objective: as evidenced pattern, as take action when there is an alteration in the pattern of  Demonstrate an
by: evidenced by
 Fatigue breathing to detect early signs of respiratory effective breathing
 Dyspnea, relaxed breathing at compromise).
 Restless pattern as
tachypnea normal rate and  Assess ABG levels, according to facility policy. (This
 Abnormal breath  Cyanosis evidenced by
depth and absence monitors oxygenation and ventilation status)
sounds
 RR- of dyspnea.  Observe for breathing patterns. (Unusual breathing
relaxed breathing
 Dyspnea, 28bpm  Patient’s respiratory patterns may imply an underlying disease process or at normal rate and
tachypnea
 HR- rate remains within dysfunction. Cheyne-Stokes respiration signifies depth and
 Cough, effective 123bpm established limits. bilateral dysfunction in the deep cerebral or absence of
with sputum
production diencephalon related with brain injury or metabolic dyspnea
abnormalities. Apneusis and ataxic breathing are  Vital signs
 Cyanosis
related with failure of the respiratory centers in the pons
 Decreased breath establish in normal
and medulla).
sounds over range.
affected lung  Auscultate breath sounds at least every four (4) hours.
(This is to detect decreased or adventitious breath
areas
sounds).
 Purulent sputum
 Monitor for diaphragmatic muscle fatigue or weakness
 Infiltrates seen on
(paradoxical motion). (Paradoxical movement of the
chest x-ray film
abdomen (an inward versus outward movement during
 RR- 28bpm
inspiration) is indicative of respiratory muscle fatigue
 HR- 123bpm and weakness).
 Observe for retractions or flaring of nostrils. (These
signs signify an increase in respiratory effort).
 Place patient with proper body alignment for maximum
breathing pattern. (A sitting position permits maximum
lung excursion and chest expansion).
Encourage sustained deep breaths by:
 Using demonstration: highlighting slow inhalation,
holding end inspiration for a few seconds, and passive
exhalation
 Utilizing incentive spirometer
 Requiring the patient to yawn
(These techniques promotes deep inspiration, which
increases oxygenation and prevents atelectasis. Controlled
breathing methods may also aid slow respirations in
patients who are tachypneic. Prolonged expiration prevents
air trapping).
 Maintain a clear airway by encouraging patient to
mobilize own secretions with successful coughing. (This
facilitates adequate clearance of secretions).
 Suction secretions, as necessary. (This is to clear
blockage in airway).
 Stay with the patient during acute episodes of
respiratory distress. (This will reduce the patient’s
anxiety, thereby reducing oxygen demand).
 Ambulate patient as tolerated with doctor’s order three
times daily. (Ambulation can further break up and move
secretions that block the airways).
 Encourage frequent rest periods and teach patient to
pace activity. (Extra activity can worsen shortness of
breath. Ensure the patient rests between strenuous
activities).
 Encourage small frequent meals. (This prevents
crowding of the diaphragm).
 Help patient with ADLs, as necessary. (This conserves
energy and avoids overexertion and fatigue).
 Educate patient or significant other proper breathing,
coughing, and splinting methods. (These allow sufficient
mobilization of secretions).
Assessment Diagnosis Planning Implementation/Rationale Evaluation

Case: Pneumonia Deficient After a series of nursing At the end of the shift
Subjective: “gusto ko Knowledge intervention, the client will:  Establish rapport through NPI the goals of the
pong malaman ang sakit related to  Patient and  Determine patient’s understanding of pneumonia intervention will be
ko “as verbalized by the Unfamiliarity caregiver will complications and its treatment regimen. (Provides seen in the patient as
patients with the verbalize a starting point in education). evidence by:
Objective: disease understanding of  Review normal lung function, pathology of  Verbalization of
process and/or condition, disease
 Requests for condition. (Promotes understanding of current understanding of
transmission of process, and situation and importance of cooperating with
information condition, disease
disease as prognosis.
 Questions to health treatment regimen).
process and
care team
evidenced by:  Patient and  Discuss debilitating aspects of disease, length of
 request for caregiver will prognosis
 Statement of convalescence, and recovery expectations. Identify
misconception
information verbalize self-care and homemaker needs. (Information can  Verbalization of
 Questions understanding of understanding of
 Failure to enhance coping and help reduce anxiety and
to health therapeutic excessive concern. Respiratory symptoms may be therapeutic
improve/recurrence
care team regimen.
 Confusion about slow to resolve, and fatigue and weakness can regimen
 Patient will initiate persist for an extended period. These factors may
treatment  Demonstrate a
 Inability to comply necessary lifestyle be associated with depression and the need for
changes. various forms of support and assistance). necessary
with treatment
regimen, including  Patient will  Provide information in written and verbal form. lifestyle changes
appropriate participate in (Fatigue and depression can affect ability to  Demonstrate of
isolation treatment program. assimilate information and follow therapeutic participation on
procedures regimen). treatment
 Reinforce importance of continuing program
effective coughing and deep-breathing exercises.
(During initial 6–8 wk. after discharge, patient is at
greatest risk for recurrence of pneumonia).
 Emphasize necessity for continuing antibiotic
therapy for prescribed period. (Full-course
antibiotic treatment is required to reduce the
recurrence of pneumonia and promote a healthy
immune system. Early discontinuation of antibiotics
may result in failure to completely resolve
infectious process and may cause recurrence or
rebound pneumonia).
 Review the importance of cessation of smoking.
(Smoking destroys tracheobronchial ciliary action,
irritates bronchial mucosa, and inhibits
alveolar macrophages, compromising body’s
natural defense against infection).
 Outline steps to enhance general health and well-
being: balanced rest and activity, well-rounded diet,
avoidance of crowds during cold/flu season and
persons with URIs. (Increases natural defense,
limits exposure to pathogens).
 Stress importance of continuing medical follow-up
and obtaining vaccinations as appropriate. (May
prevent recurrence of pneumonia and/or related
complications).
 Identify signs and symptoms requiring notification
of health care provider: increasing dyspnea, chest
pain, prolonged fatigue, weight loss, fever,
chills, persistence of productive cough, changes in
mentation. (Prompt evaluation and timely
intervention may prevent complications).
Case: chicken pox Hyperthermia After a series of nursing At the end of the shift
Subjective: “nilalagnat related to viral intervention, the client will:  Establish rapport through NPI the goals of the
ako “as verbalized by the infection as  The patient will  Provide isolation or monitor visitor as indicated. intervention will be
patients evidenced by demonstrate (body substance isolation should be used for all seen in the patient as
Objective: elevated temperature within infectious patients and patients with disease evidence by:
 Warm to touch temperature of normal range and transmitted through air may also need airborne and  Demonstrate
38 will experience no
 Irritability droplet precautions). temperature
 Petechiae associated  Wash hands with anti bacterial soap before or after within normal
 V/s taken as complications care of the patients. (reduce the risk of spreading
range and
follows: the infections).
experienced no
Temp- 38  Encourage patient to cover mouth and nose during
Pulse- 93 cough and sneezes. (Prevents the spread of associated
RR- 23 infection through airborne droplet). complications.
BP- 120/80  Monitor patient temperature degree in pattern.
(fever patter aids in the disease process and
diagnosis).
 Observe for chills and profuse diaphoresis. (chills
often precede temperature spikes in presence of
generalized infections).
 Monitor environmental temperature. (room
temperature should be altered to maintain near
normal body temperature).
 Provide tepid sponge bath, avoiding the use of
alcohol. (may help reduce the fever)
 Encourage use calamine lotion. (to help reduce the
itchiness).
 Administer antipyretic as indicated. (used to reduce
the fever by its central action on the
hypothalamus).
Case: chicken pox Impaired skin After a series of nursing At the end of the shift
Subjective: “nagsisimula integrity intervention, the client will:  Establish rapport through NPI the goals of the
na para lumabas at unti related to  will be  Monitor vital signs especially temperature. (serve intervention will be
unting pumuputok at exposure to able to as baseline data). seen in the patient as
nagsusugat ang mga Varicella-zoster understand the  Bath with cool water. (this would help ease the evidence by:
bulutong ka“as verbalized virus as disease process, its itchiness).  verbalized
evidenced by signs and
by the patients  Kept area clean and dry. (to stimulate normal body understanding on
dry vesicle symptoms,
Objective: temperature). the disease
lesions on the prevention,
 Alert  Encourage family who touched patient to use anti process, its signs
entire body control
 Coherent bacterial soaps before and after care. (reduce risk
and symptoms,
 will of spreading infection).
 Afebrile demonstrate prevention and
 Presence of dry  Avoid salty and acidic foods. (this may trigger
techniques to irritation of the skin). control.
vesicular rashes prevent spread of  Advise visitor to cover mouth and nose during  Demonstrated
 Lesions on the infection coughing and sneezing. (prevents spread of techniques to
trunk, abdominal, infection via airborne droplet). prevent the
face and  Use calamine lotion. (help relieve itchiness).
extremities spread of
 Wet compress can be done infections.
 Small drainage of
blood noted on the
right chest region
Case: chicken pox Acute pain After a series of nursing At the end of the shift
Subjective: “I am in pain related to intervention, the client will:  Establish rapport through NPI. (to gain trust and the goals of the
“as verbalized by the inflammatory  Report decrease cooperation of the patients). intervention will be
patients process as seen in the patient as
pain  Monitor and record vital signs. (to provide baseline
Objective: evidenced by evidence by:
pain scale of data).
 Appears week  The patient level
7/10  Review factor that aggravate and alleviate pain.
 Limited range of of pain decrease
(helpful in establishing diagnosis and treatment
motion as evidenced by
needs).
 Restlessness pain scale of 4/10
 Encourage non pharmacologic measures to reduce
 Facial grimaces
pain like deep breathing exercises. (to promote
 Irritability
comfort).
 Sleep disturbances
 Pain scale of 7/10  Provide adequate rest. (to promote healing).
 Provide diversional activities like socialization. (for
client’s comfort and relieve pain).
 Administer analgesics to maintain acceptable level
of pain if not contraindicated. (to decrease pain).
Case: chicken pox Disturbed body After a series of nursing At the end of the shift
Subjective: “Ang dami ko image related intervention, the client will:  Establish rapport through NPI. (to gain trust and the goals of the
pong sugat sa katawan to skin lesions  demonstrate positive cooperation of the patients). intervention will be
dahil sa bulutong “as as evidenced body image, as seen in the patient as
 Assess meaning of change to patient including
verbalized by the patients by lesions on evidenced by the ability evidence by:
future expectations and impact of cultural or
Objective: the trunk, to look at, talk about,  Client
religious beliefs. (The extent of response is more
abdominal, and care for lesions.
 Presence of dry related to the value or importance the patient demonstrated
face and positive body
vesicular rashes places in the part or function than the actual value
extremities image, as
 Lesions on the or importance).
trunk, abdominal,  Assess the perceived impact of change in ADLs, evidenced by the
face and social participation, personal relationships, and ability to look at,
occupational activities. (Alteration in body image talk about, and
extremities
 Small drainage of can have an effect on the patient’s ability to carry care for lesions.
out daily roles and responsibilities).
blood noted on the
 Set limits on maladaptive behavior. Maintain
right chest region
nonjudgmental attitude while giving care, and help
 irritability patient identify positive behaviors that will aid in
recovery. (Patient tend to deal with this crisis in the
same way in which they have dealt with problems
in the past. Staff may find it difficult
and frustrating to handle behavior that is disrupting
and not helpful to recuperation but should realize
that the behavior is usually directed toward the
situation and not the caregiver).
 Exhibit positive caring in routine activities. (Positive
remarks by the nurse may encourage the patient
develop more positive responses to the changes in
his or her body).
 Provide thorough teaching and complete aftercare
instructions for the patient.( Reinforcing teaching
can help patient achieve self-care).
Case: chicken pox Deficient After a series of nursing At the end of the shift
Subjective: ““as knowledge about intervention, the client will:  Establish rapport through NPI. (to gain trust and the goals of the
verbalized by the patients the condition  will verbalize feelings cooperation of the patients). intervention will be
Objective: and treatment about lesions and seen in the patient as
 Assess motivation and willingness of patient to
 Irritability needs. continues daily evidence by:
learn. (Learning requires energy. Patients must
 Confusion behavior activities see a need or purpose for learning. They also  Client had
 Afebrile  will have minimal risk have the right to refuse educational services). minimal risk for
for disease  disease
 Presence of dry Observe and note
transmission through existing misconceptions regarding material to be transmission
vesicular rashes
the use of universal through the use
 Agitated taught.( Assessment provides an important starting
precautions. point in education. Knowledge serves to correct of universal
faulty ideas). precautions.
 Consider the patient’s learning style, especially if  Client verbalized
the patient has learned and retained new feelings about
information in the past. (Every individual has his or lesions and
her learning style, which must be a factor in continues daily
planning an educational program. Some may activities.
prefer written materials over visual materials, while
others prefer group sessions over an individual
instruction. Matching the learner’s preferred style
with the educational method will facilitate success
in mastery of knowledge).
 Determine the patient’s self-efficacy to learn and
apply new knowledge. (Self-efficacy refers to a
person’s confidence in his or her own ability to
perform a behavior. A first step in teaching may be
to foster increased self-efficacy in the learner’s
ability to learn the desired information or skills.
Some lifestyle changes).
 Render physical comfort for the patient. (Based on
Maslow’s theory, basic physiological needs must
be addressed before the patient education.
Ensuring physical comfort allows the patient to
concentrate on what is being discussed or
demonstrated).
 Grant a calm and peaceful environment without
interruption. (A calm environment allows the
patient to concentrate and focus more completely).
 Provide an atmosphere of respect, openness,
trust, and collaboration. (Conveying respect is
especially important when providing education to
patients with different values and beliefs about
health and illness).
 Include the patient in creating the teaching plan,
beginning with establishing objectives and goals
for learning at the beginning of the session. (Goal
setting allows the learner to know what will be
discussed and expected during the session. Adults
tend to focus on here-and-now, problem-centered
education).
 Consider what is important to the patient. (Allowing
the patient to identify the most significant content
to be presented first is the most effective).
 Involve patient in writing specific outcomes for the
teaching session, such as identifying what is most
important to learn from their viewpoint and lifestyle.
(Patient involvement improves compliance with
health regimen and makes teaching and learning a
partnership).
 Support self-directed, self-designed learning.
(Patients know what difficulties will transpire in
their own environments, and they must be
encouraged to approach learning activities from
their priority needs).
 Provide clear, thorough, and understandable
explanations and demonstrations. (Patients are
better able to ask questions when they have basic
information about what to expect).
 When presenting a material, start with the basics
or familiar, simple, and concrete information to less
familiar, complex ones. (This method allows the
patient to understand new material in relation to
familiar material).
Use the teach-back technique to determine the
patient’s understanding of what was taught:
 The nurse gives information in a caring
manner, using plain language.
 Ask the patient to explain in his or her own
words.
 Rephrase the information if unable to repeat it
accurately.
 Again ask the patient to teach-back the
information using his or her own words until the
nurse is comfortable that is understood.
 If the patient still does not understand,
consider other strategies.
(The teach-back technique consists of specific steps in
a repetitive order to evaluate the recipient’s knowledge
of the content discussed. Patients who are not able to
do this method after multiple cycles is considered
cognitively impaired).
 Encourage questions. (Questions facilitate
open communication between patient and
health care professionals and allow verification
of understanding of given information).
 Note progress of teaching and learning.
(Documentation allows additional teaching to
be based on what the learner has completed).

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