Assessment Nursing Rationale Outcome Intervention Rationale Evaluation

Diagnosis Identification
S: “Ok naman ako Imbalanced Malnutrition After 8 hours of v/s taken and *in order to get  Patient
kaya lang dikitun ako Nutrition: Less maybe a nursing recorded the baseline data verbalize
mag kakan” as than body consequence intervention understanding
verbalized by the pt. requirements of the pt’s the pt will of importance
O: r/t inadequate lifestyle, lack verbalized I and O * Determination of of balance
 Slightly Pale in food intake of knowledge understanding monitored amount of fluid nutrition
appearance about the importance intake and output.  Demonstrates
 Decreased adequate of proper Encourage *to know the behavior
subcutaneous nutrition and nutrition and verbalization of perception of changes to
fats its role in exercise feelings client regain
 Poor skin health appropriate
turgor maintenance, Kept safe and weight
 Weak in lack of comfortable in *in order to avoid  Able to ingest
appearance resources, lack bed accidents increase fluid
 Limited ROM of appetite. intake and
 Lack of Reinforced foods rich in
appetite adequate rest *to regain energy vitamins.
 BP=100/70 period and to avoid  Able to
T=36.7 straining consume
P=90 Recommende
R=18 Referred to d Daily
dietitian for *Dietitians have a Allowances
further greater (RDA)
assessment and understanding of  Still pale in
recommendations the nutritional appearance,
regarding food value of foods and poor skin
preferences and may be helpful in torpor.
nutritional assessing specific
support ethnic or cultural
foods
Facilitated proper
position while *Elevating the
eating and head of bed 30
observed SAP. degrees aids in
swallowing and
reduces risk of
Provided good aspiration.
oral hygiene *in order to give
comfort to the
patient through
feeling clean and
Provide fresh
companionship * Attention to the
during mealtime. social aspects of
eating is
important in both
the hospital and
Encouraged to home settings.
increase fluid * Supplemental
intake at least 8 nutrition, to
glasses of water a enhance wound
day and eat foods healing and regain
reach in protein, energy.
carbohydrates,
and vitamins.

Discourage
beverages that * These may
are caffeinated or decrease appetite
carbonated. and lead to early
satiety.
Encouraged
ambulation and * Metabolism and
passive Rom utilization of
nutrients are
enhanced by
Health teaching activity.
rendered:
 The basic
four food * Foods high in
groups, as calories and
well as protein that will
the need promote weight
for gain and nitrogen
specific balance
minerals
or
vitamins.
Assessment Nursing Rationale Outcome Intervention Rationale Evaluation
Diagnosis Identification
S:”Mayo pa si aki ko Risk for Inadequate After 8 hours of v/s taken and *to get baseline  Patient
na may dara kang infection r/t natural nursing recorded data verbalized
pang linig dgdi ska post op defense intervention the understand
pang ribay sa surgery mechanisms to pt will Maintain clean *to avoid ways on
colostomy bag” as protect from understand technique in invasion of preventing
verbalized by the pt. the inevitable ways on cleaning and microorganisms infection and
injuries preventing changing the ways to
O: infection and to colostomy bag reduce further
 Weak in reduce further complication.
appearance Breaks in the complication Instructed to *To promote  Able to
 Poor muscle integument, perform passive proper demonstrate
tone the body’s first ROM circulation proper
 With line of colostomy
colostomy bag defenses Instructed client to care and hand
 With JP (surgical limit visitors * This reduces washing
drainage opening) the number of  Verbalized
draining well. organisms in understanding
patient’s the
Pt’s immune environment and importance of
system cannot restricts proper
combat the visitation by hygiene and
invading individuals with identified s/sx
organism any type of of infection.
adequately infection to  Still weak in
reduce the appearance
transmission of
pathogens to the
patient at risk for
Observed for any infection.
untoward s/sx such *to assess the
as redness, signs of infection
swelling, increased
pain, or purulent
drainage at
incisions, injured
sites.

Encourage intake
of protein- and *This maintains
calorie-rich foods. optimal
nutritional
Encourage status.
coughing and deep *These measures
breathing; consider reduce stasis of
use of incentive secretions in the
spirometer. lungs and
bronchial tree.
When stasis
occurs,
pathogens can
cause upper
respiratory
infections,
including
Health teaching pneumonia.
given:
 Teach
patient and *To lessen
significant microorganisms;
others to Patients and
wash caregivers can
hands spread infection
 often, from one part of
especially the body to
after another, as well
toileting, as pick up
before surface
meals, and pathogens; hand
before and washing reduces
after these risks.
administeri
ng self-
care.

 Teach
patient the
signs and *To give
symptoms immediate
of intervention
infection,
and when
to report
these to
the
physician
or nurse.
 Demonstra
tes steps in
applying *to provide the
colostomy, pt independence
identified in caring for the
equipment colostomy
s needed
with
colostomy
care and
 allow
return
demonstra
tion.
 Reviewed
importance
of proper * To lessen
hygiene microorganisms
Assessment Nursing Rationale Outcome Intervention Rationale Evaluation
Diagnosis Identification
S: Self Care Deficit Result of After 8 hours of Assessed ability to *The patient may  Pt was able to
O: r/t transient progressive nursing carry out ADLs (on only require demonstrate
 Weakness limitations due deterioration intervention the regular basis and assistance with increased
 Lack of to presence of that erodes pt will determine the some self-care ability to
motivation colostomy and the demonstrates: aspects of self measures. dress/groom
 With JP drain. individual’s care that are self and
discomfort ability or a. Patient problematic to the perform ADL.
due to willingness to safely patient.  Still weak in
presence of perform the perform appearance
colostomy activities s (to Assessed patient’s *This increases  Slow walking
and JP drain required to maximu need for assistive independence in
 Impaired care for m devices. ADLs
transfer himself or ability) performance.
ability herself. self-care Identified * These support
activitie preferences for patient’s
s. food, personal individual and
Patient with b. Optimiz care items, and personal
physical ing the other things. preferences.
limitations autono
due to my and Assisted patient in * Patient may
colostomy accepting need to grieve
indepe
and JP drain necessary amount before accepting
ndence
this is a of dependence. that dependence
hindrance to of the is possible.
perform patient.
normal c. Perform Set short-ranged * Assisting the
personal self care goals with patient. patient to set
function. activitie realistic goals will
s within
 level of decrease
own frustration.
ability Encouraged *An appropriate
d. Demons independence, level of assistive
trate but intervene care can prevent
ability when patient injury with
to cope cannot perform. activities without
with the causing
necessit frustration.
y of Provided positive *This provides the
having reinforcement for patient with an
someon all activities external source of
e else attempted; note positive
assist partial reinforcement.
him/her achievements.
in
perform Ensured that *Deficits may be
ing the patient wears exaggerated if
task. dentures and other senses or
eyeglasses if strengths are not
needed. functioning
optimally.
Provided privacy *Patients may
during dressing. take longer to
dress and may be
fearful of
breaches in
Encouraged use of privacy.
clothing one size *This ensures
larger. easier dressing
and comfort.
Maintained
privacy during *The need for
bathing as privacy is
appropriate. fundamental for
most patients.
Assist edpatient *Patients may
with care of require podiatric
fingernails and care to prevent
toenails as injury to feet
required. during nail
trimming or
because special
implements are
required to cut
Provide dprivacy nails.
while patient is *Lack of privacy
toileting. may inhibit the
patient’s ability to
evacuate bowel
Assisted patient in and bladder
removing or *Clothing that is
replacing difficult to get in
necessary and out of may
clothing. compromise a
patient’s ability to
Teached family to be continent.
foster * This
independence and demonstrates
to intervene if the caring and
patient becomes concern but does
fatigued, is unable not interfere with
to perform task, patient’s efforts to
or becomes achieve
excessively independence.
frustrated.