Assessment Explana Planning Intervention Rationale Evaluatio

tion of n
problem
Subjective: Choleli Short term: - Assess pain - because it can Short
“Masakit thiasis withing 4 hours level every provide direction term:
parin sa may is the of nursing 1 hour for pain treatment
tiyan banda, formati interventions, plan and adjustments After 4
tapos on of the patient will can be made client’s hours of
lumilipat sa gallsto be able to response  Nursing
may likod ko, nes experience gradual - Provide - T o p r o v i d e non intervent
- 6/10, which reduction/relief comfort pharmacologic pain ion,
left are of pain to a measures management patient
upper compose pain scale of verbalize
quadrant d of 3/10. - Provide - to relieve pain in the d relieve
,radiati cholest application muscle area. of pain
ng to erol, of hot and to a pain
the calcium Long term : cold scale of
back, salts compress. 3/10
pricking and After 2-3 days
pains bile, of nursing Long
Objective: when intervention the term:
- Guarding the patient should
- Administer - to help control the
and gallsto be able to After 2-3
prn pain pain
grimacin nes verbalize that days of
medications
g block there’s total nursing
to help
- With the relieve of pain intervent
control the
limited flow of ion, the
severe pain
movement bile, patient
the was able
- BP-
gall to
120/100 - Encourag - Deep breathing fo
bladder verbalize
- PR-120 becomes e and r   relaxation is easy the total
swollen assist to learn and relieve
Nursing which client to contributes to pain of pain
Diagnosis results do deep relief
Acute pain to breathing
related to pain. exercises
inflammati
on process - Encoura - The human body
ge is believed to have
relatives energy fields that
to perform express
touch aberrant patterns when
therapy body systems are
insulted. Therapeutic
Touch is thought to
realign aberrant
fields. 
2. DISTURBED SLEEPING PATTERN

ASSESSMENT EXPLANATION PLANNING INTERVENTION RATIONALE EVALUATION

OF PROBLEM
Subjective Due to the Short term: - Assess sleep - High Short term:
:“Paputol-putol patient within 4 pattern percentage
yung tulog being hours disturbances of sleep After 4
naming dito kasi hospitalized of nursing that are disturbanc hours of
maya’t maya may , she has to interventions associated es can Nursing
mga pumapasok na sleep in the , the patient with the affect the intervention
tao eh.” hospital will be able environment. recovery , patient
also which to sleep all of the was able to
Objective has many to sleep patient.  sleep all
:• Presence patients and through the
of eye bags. nurses which - Observe and - To night.
• Weakness and might be Long term: obtain feed determine
restlessness. noisy at within 3 days backs usual
•Taking nap when night and of nursing regarding on sleeping Long term:
there is a chance also the interventions the usual pattern
or if there is a hospital , the patient sleeping and to After 3-4
free time. light might will be able pattern, compare if days of
•Yawning not be to adjust to bedtime there are Nursing
turned off the routine and any intervention
NURSING at night and environment the usual improvemen , patient
DIAGNOSIS: also the and also will number ts on the was able to
nurses have no more of hours of sleeping
Disturbed having their complains of rest. pattern of
sleeping pattern round sleep the
r/t therefore disturbance patient. 
interruptions disturbing
for therapeutics the patients
, sleep
monitoring ,other leading to
generated disturbed - Do as much - To avoid
awakening, and sleep care as disturbanc
excessive pattern. possible es during
stimulation(noise without sleep, and
and lighting) waking up also to
the client maximize
and do as the sleep
much care as and rest
possible of the
while the client.
client is
still awake.

- Explain - For the

necessity patient to
of disturban have an
ces for understand
monitoring ing of the
Vital Signs importance
and care of care
when being done
hospitalized. to her and
to
minimize
the
complain.
3.RISK FOR Imbalanced Nutrition Less Than Body Requirements 

Assessment Explanation Planning Intervention Rationale Evaluation

of Problem
Subjective: Because the Short term: - Determine - Early Short term:
Pt complains of patient have within 4 healthy diagnosis
nausea cholelithiasi hours body weight and a After 4
s which of nursing for age and holistic hours of
results to interventions height. team Nursing
    inflammation , the patient Refer to treatment intervention
Subjective: in the will be able dietitian of eating , patient
    abdomen and to eat about for disorders was able to
- Ate only also 75% of food complete are eat 75% of
about 25% intestinal served nutrition desirable. food served
of Obtruction assessment
breakfast which would if 10% Long term::
tray. result to the Long term: under
- Changes in patient loing within 3 days healthy After 3 days
gastric appetite to of nursing body weight of Nursing
motility eat and also interventions or if intervention
and stool induces , the patient rapidly - To be able , patient
characteri nausea . will be able losing to know if was able to
stic to eat all weight. the problem eat all food
- Lack of the food - Observe of the served and
interest served client's patient is verbalized
 in food, without any ability to difficulty that there’s
aversion complains of eat (time in no more
to eating, nausea involved, swallowing feeling of
altered motor nausea
taste skills,
sensation visual
acuity,
Nursing ability to
Diagnosis: swallow
Imbalanced various - because
Nutrition Less textures patients will
Than Body often eat more
Requirements  - Provide if other people
companionsh are present at
ip while meal time
eating to
encourage
eating  - Calms down
peristalsis
and boosts
- Advocate available
rest before energy for
meals eating.

- These
action may
be helpful
-  Avoid in
food(s) escalating
that food
provoke intake.
 nausea or
vomiting
- Restores
vitamin or
- Give mineral
multivitami insufficien
ns, cies
together resulting
with from
ascorbic malnutritio
acid n
(vitamin
C), folic
acid,
vitamins
B6 and D,
and iron - to decrease
supplements nausea when
, as eating and
ordered. with
medication
- Administer intake so
antiemetic that the
medicine patient is
prn more
willing to
eat
- These may
reduce
appetite
and result
to early
- Encourage satiety.
to Avoid
beverages
that are - Makes the
caffeinated most of
or nutrient
carbonated intake
without
- Persuade unnecessary
small, fatigue or
frequent energy loss
meals with from eating
foods high large
in protein meals, and
and diminishes
carbohydrat gastric
es irritation.