ASSESSMENT: NURSING CLIENT OUTCOME NURSING  

 
CUES AND DIAGNOSIS: Planning IMPLEMENTATIONS/ RATIONALE EVALUATION
CLUES (Problem+Etiolog INTERVENTIONS
Signs and y)
Symptoms
ASSESSMENT: CUES   NURSING CLIENT Independent:
NURSING        
AND CLUES FatigueDIAGNOSIS:RT Short Term:
OUTCOME IMPLEMENTATIONS/ RATIONALE After 8 hours of
EVALUATION
Subjective
Signs and Cues:
Symptoms decreased
(Problem+Etiolo Planning  Establish nurse-patient
INTERVENTIONS To establish rapport nursing
 “ Hindi ako hemoglobin and
gy) After 8 hours of nursing relationship interventions, the
masyado nagkikilos diminished oxygen- intervention, the patient client was able to
   
ngayon kasi Cues: carrying capacity willShort
showTerm:
signs of Assess patient’s ability to Influences choice of show signs of
Subjective Fluid volume Independent: Atimproved
the end of the
napapagod ako.”as of the blood improved tolerance in perform normal task or interventions or
deficit RT   shift, the inclient
verbalized by the doing physical activity w/o activities. needed rapport
assistance. tolerance doing
“Andaming lumalabas excessive blood After 8 hours of Establish nurse-patient To establish was able activity
to
patient experiencing fatigue physical
na dugo kapag nireregla loss during nursing relationship understand about
w/o experiencing
  menstruation.   interventions, the Provide quiet atmosphere and Enhances rest to menstrual period
ako.”as verbalized by fatigue.
  client will verbalize relaxed environment. lower body’s oxygen regarding blood
the patient. Monitor VS To obtain baseline data
Objective Cues:
“Kapag may mens ako, understanding about Promote bed rest. requirements, and loss.
After 2-3 days of
3-4 ng The
besespatient
ako Long Term
menstrual period Monitor amount of bleeding
reduces strain on
To monitor blood
is always
nagpapalit ng napkin.”as regarding blood loss. by weighing all pads used. the heart andloss
lungs nursing
The patient was
lying. After 2-3 days of nursing intervention, the
verbalized by the   able
intervention, the patient patientshow
to waysto
was able
 Easy
patient.   Assisttopatient
Explain to establish
the patient about a
To reduce fatigue onreport
how increased
to managein
will report increased in balance For the
activity and rest. Promotes
betweencycle patientwell
to be aware
being and
  fatiguability Long Term: blood
energy and will do normal menstrual for the normal
maximize energy or excessive energy loss and by did
   With limited After 2-3 days of eating
things foods rich
activities w/o assistance. bloodproduction
loss.
Objective Cues:
movement nursing intervention, inindependently.
iron.
  the patient will show
  Labored
Pale skin Assist patient in self-care needs
ways on how to and with ambulation as To protect the patient
 breathing
Easy Encourage patient to eat foods Iron rich injury
food will help
manage blood loss needed. from
 Looksfatiguability
tired rich in iron. replace blood loss.
like eating foods Elevate the head of
  VS Looks tired
rich in iron. Enhances lung
the bed as tolerated
 T:36.5
VS   expansion to maximize
BP:110/60
T:36.5 Promote rest For the patient notforto disrupt
oxygenation
PR:71bpm
BP:110/60 normal activities.
cellular uptake.
RR:24cpm
PR:71bpm
RR:24cpm Note daily energy patterns
Promote comfort measures To prevent
Helpful stress and anxiety
in determining
  timing/pattern of activity

     Identify or implement energy Encourages patient to

Interdependent: To
saving technique like sitting while do as
obtain much
baseline as
data
Ask for lab
doing test(Hgb/Hct)
a task. possible, while
conserving limited
energynutrition
For proper and
Refer for a dietician for proper preventing fatigue
dier
NURSING CLIENT NURSING    
Interdependent:
Dependent: To treat excessive blood loss
Administer meds as To maintain strength and
Refer to physical therapy for
prescribed. muscle tone and to
 ASSESSMENT: CUES DIAGNOSIS: OUTCOME IMPLEMENTATIONS/ RATIONALE EVALUATION
AND CLUES (Problem+Etiolo Planning INTERVENTIONS
Signs and Symptoms gy)

Subjective: Fear, related to After 8 hours of Discussed treatment To have full disclosure Goal met. After 8
“Hindi ko inaasahan na diagnosis of nursing alternatives, including the with patient regarding hours of nursing
ganito na pala” as cervical cancer intervention, the prognosis with treatment regimen intervention, the
verbalized by the patient. client will be able each option patient shows
to verbalize and signs of increased
Objective: express her Provided due medications as To provide treatment comfort and is
feelings about the prescribed by the physician and relief able to verbalize
Vital Signs: fear of cancer and and share feelings
T: death. Provided information on To alleviate stress and of fear and
HR: biofeedback training and increase comfort level anxiety regarding
RR: relaxation techniques. of the patient her condition.
BP:
Referred a local cancer To provide an emotional
Positive test for squamous support group so that she can support system wherein
cell carcinoma of the interact with cancer the patient can openly
cervix. survivors. verbalize feelings of
fear/anxiaety