NURSING

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Activity intolerance Patient will improve Independent Patient demonstrated
“Agkakapsot nak met related to body mobility Assess patient’s level This aids in in improved mobility
ti rikna kon ading” as weakness. participation in the of mobility. defining what patient participation in
verbalized by the daily living. is capable of, which
activity of daily living
patient. is necessary before
setting realistic in which she is
goals. capable of.
Objective
Vital signs as Monitor vital signs. Serve as baseline
follows: data.
BP: 160/100 mmHg
PR: 88 bpm Place the client in a To prevent
RR: 21 cpm backaches or muscle
comfortable position.
Temp: 36.3°C aches.

Refrain from Rest between

performing non- activities provides
essential procedures. time for energy
conservation and
recovery.
Encourage active ROM
Exercises maintain
exercises three times muscle strength and
daily. join ROM.

Collaborative To improved
Administer percentage of
medications, as ordered patients meeting
by the physician. their health care
goals.
 NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Impaired skin Following a 3-day Independent At the end of the 3-
“naut-ot pay laeng” as integrity related to nursing day nursing
verbalized by the wound dressing. intervention, the Assess skin. Note for Establishes intervention, the client
patient. client will be able color, turgor, and comparative baseline was able to display
to display providing improvement in
sensation. Describe and
Objective improvement in opportunity for wound healing as
S/P: wound healing as measure wounds, and timely intervention. evidenced by:
> Wound dressing. evidenced by: observe changes.
Vital signs as follows:  Minimize
BP: 160/100 mmHg  Minimize Demonstrate good skin Maintaining clean presence of
PR: 88 bpm presence of hygiene, wash dry skin provides a wound.
RR: 21 cpm wound. thoroughly, and pat dry barrier to infection.  Absence of
Temp: 36.3°C  Absence of Patting skin dry redness,
carefully.
redness, instead of rubbing purulent
purulent reduces risk of discharge,
discharge, dermal trauma to itchiness
itchiness. fragile skin.

Instruct significant Skin friction caused

others to maintain clean by stiff or cough
clothes leads to
and dry clothes,
irritation or fragile
preferably cotton fabric. skin and increases
risk of infection.

Assist in passive
movements, such as bed To examine skin
turning and passive integrity, monitor
 ROM turning and progress of healing,
passive ROM exercise and identify need for
and active exercise after further.
movements such as bed
position, sitting,
standing, walkig.

Collaborative
Encourage patient to To allow continuous
verbalized for any monitoring and
untoward feelings assessment of patient
especially pain, condition.
discomfort as well as
changes noted on
operative site.

NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Risk for infection After 8 hours of Independent After 8 hours of
“Haan met umim- related to high nursing Observe for signs of Patient may be nursing interventions,
imbag etoy sugat kon glucose levels, interventions, the infection and admitted with the patient was able to
nakkong” as decreased leukocyte patient will identify inflammation. infection already, identify interventions
verbalized by the function. interventions to which could have on how to prevent or
patient. prevent or reduce precipitated the keto- reduce risk of
risk of infection. acidotic state or may infection.
develop a
Objective nosocomial
●Flushed appearance infection.
●Non-healing wound
with purulent. Promote proper
Vital signs taken as handwashing by nurse Reduces the risk of
follows: and patient. cross-contamination.
BP: 160/100 mmHg
PR: 88 bpm
Temp: 36.3°C
O2Sat: 97 % Encourage adequate
dietary and fluid intake Decrease
of 3000 ml/day. susceptibility to
infection.

Collaborative
Administer
medications, as ordered To improved
by the physician. percentage of
patients meeting
their health care
goals.

NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Activity intolerance After 8 hours of Independent After 8 hours of
“maulaw nak ading” related to dizziness. nursing Establish rapport. To facilitate nurse- nursing intervention
as verbalized by the intervention the patient interaction. the patient
patient. patient will demonstrated
improve mobility improved mobility
Position the patient in a
Objective participation in the To prevent participation in
●conscious activities of daily comfortable position. backaches or muscle activities of daily in
●dizziness living. aches. which she is capable
BP: 160/100 mmHg of.
PR: 88 bpm  Minimize Monitor vital signs. To note any
Temp: 36.3°C presence of significant changes
O2Sat: 97 % wound. that may be bought
 Absence of by the disease.
redness,
purulent Determine patient’s
discharge, Assessment for
perception of causes of guide treatment.
itchiness.
fatigue or activity
intolerance.

Assess patient’s level of Aids in defining

mobility. what patient is
capable of which is
necessary.

Assess nutritional Adequate energy

status. reserves are required
for activity.

Encourage adequate
Rest between
rest periods especially
activities provides
before meals, other time for energy
ADL’s and ambulation. conservation and
recovery.

Collaborative

Obtain specimen for Identifies organisms

culture and sensitivities to the most
as indicated. appropriate drug
therapy can be
instituted.