Name: Age: Sex: Date Admitted: Admitted via:

Physician: Room & Bed No.: Admitting diagnosis:

Date/ CUES NEED NURSING OBJECTIVE OF NURSING INTERVENTIONS EVALUATION
Time / DIAGNOSIS CARE with
Shift RATIONALE
Subjective:
08/23/1 At the end of the 1. Establish an atmosphere of trust Goal Met.
7 “Unsaon pag C Deficient 8-hour shift, the
gamit anang O knowledge client will be able R- An atmosphere of trust promotes At the end of the
@11am gi tudlo ninyo G related to to explain and client cooperation. 8-hour shift, the
ganiha sir” N insufficient demonstrate a client was able
7-3pm I information on proper family 2. Determine and analyze the to explain and
Objective: T family planning planning method client’s reproductive needs. demonstrate
I techniques. of choice. how to correctly
1. VS: O R- Knowing whether the client use the Standard
T – 36.8˚C N wants a short, long, or permanent Days Method.
P – 92 bpm family planning method allows
R – 19 organization of information to be
breaths/min provided.
BP – 110/70
mmHg 3. Assess prior knowledge and
Rationale: history on family planning use.
2. Expressing
confusion. R- Determining what the client
already knows gives an estimated
3. Questioning Source: starting point for the counselling
members of approach.
health care
team. 4. Educate the client on the different
family planning methods based on
4. Expressing her need, and present advantages
frustration and disadvantages of each
from getting
pregnant R – Explaining that each method
again. has pros and cons provides the
client with an informed consent.
5. Expressing
irregular 5. Provide a demonstration on how
timing of pill to properly use family planning
ingestion in methods.
the past.
R- A demonstration helps the client
6. Expressing visualize the concepts being taught.
past IUD
complications. 6. Provide family planning
pamphlets or visual aids.