Assessment Diagnosis

NCP
Planning Interventions Rationale Evaluations
“Nagmamanas po tong paa ko Excess fluid volume related After 6 hours of nursing  Determine or  Potential exists for After 6 hours of nursing
sinasabi ko po sa mga nurse at to excessive fluid retention interventions the patient will estimate the amount fluid overload due intervention the patient were
mga Doctors po” as verbalized verbalize understanding of of fluid intake from all to fluid shifts and able to verbalize and
by the patient individual dietary and fluid source: Oral, IV, changes in understand the individual
restrictions. Enteral, or parenteral electrolyte dietary and fluid restriction. –
Objective: feedings, ventilator balances. Goal met
Presence of edema on left After 8 hours of nursing and so forth.  Imbalances in
lower extremities interventions the patient will  Review nutritional these areas are After 8 hours of nursing
Alteration in Blood pressure demonstrate behaviors to issues (e.g., intake of associated with interventions the patient
monitor fluid status and sodium, potassium, fluid imbalances. were able demonstrate the
Vital Signs reduce recurrence of fluid and protein).  Heart failure and behavior to monitor the fluid
BP: 140/90 MmHg excess.  Note the presence renal failure are status and reduce recurrence
RR: 22 cpm and location of associated with of fluid excess. –Goal Met
HR: 88 bpm edema (puffy eyelids, dependent edema
T: 36.5 c dependent swelling of because of
ankles and feet if hydrostatic
ambulatory or up in pressures with
chair; sacrum and dependent edema
posterior thighs when being a defining
recumbent), characteristics for
anasarca. excess fluid.
 Review laboratory  To evaluate the
data (e.g., blood urea degree of fluid and
nitrogen/creatinine electrolyte
(BUN/Cr), imbalance and
hemoglobin response to
(Hb)/Hematocrit therapies.
(Hct), serum  Reducing
alteration, proteins, congestion and
NCP and electrolytes; edema if heart
urine-specific gravity failure is the cause
and osmolality, of fluid overload.
sodium excretion)
chest x-ray.
 Administer
medications (e.g.,
diuretics,
cardiotonics, steroid
replacements, plasma
or albumin volume
expanders)
 Assessment Diagnosis
NCP
Planning Interventions Rationale Evaluation
Subjective Acute pain related to After 6 hours of nursing  Determine and  Acute pain is that After 6 hours of nursing
“masakit dito ko (pelvic) pag physical injury secondary to interventions, the patient document presence which follows an interventions, the patient
gumagalaw ako” as fractures will be able to experience of possible injury trauma, or was able to experienced
verbalized by the patient gradual reduction /relief of pathophysiological procedure such as gradual a relief of pain.
pain. and psychological surgery, or occurs
Objective causes of pain (e.g., suddenly onset of a After the series of nursing
Exhibited facial grimace upon After the series of nursing inflammation, painful condition. interventions, the patient
movement of the body interventions, the patient tissue trauma,  To help determine was able to:
Pain Scale of 9 for the pain on will be able to: fractures, surgery, possibility of 1. Verbalized the relief
the pelvic 1. Verbalize reduction/ infections, heart underlying condition of pain
RR: 22cpm relief of pain attack or angina, or organ dysfunction 2. Verbalized the sense
2. Verbalize sense of abdominal requiring treatment. of control of sense of
control of sense of conditions (e.g.,  To demonstrate response to acute
response to acute appendicitis, improvement in situation and
situation and cholecystitis) burns, status or to identify positive outlook
positive outlook for grief, fear, anxiety, worsening of 3. Verbalized the non-
the future. depression, and underlying condition/ pharmacological
3. Verbalize non- personality developing condition. methods that
pharmacological disorder.  This are usually provide relief.
methods that  Assess for referred altered in acute pain.
provide relief. pain, as appropriate  This can affect
 Perform pain responses to
assessment each analgesics and choice
time pain occurs. of interventions for
Document and pain management.
investigate changes
from previous
reports and
NCP evaluate results of
pain interventions.
 Monitor skin color
and temperature
and vital signs.
 Determine factors
in client’s lifestyle.