ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS EVALUATION

Objective Data: Risk for bleeding Short Term: Independent: Goals met as evidenced by
Platelet count test results: related to decreased After 1 hour of nursing  Monitored laboratory tests. the following
 May 21, 2022: 67, 000 platelet count. intervention, the patient and Rationale: For baseline data to check manifestations:
cells/mm3 parents will be able to: current responses.  The patient and his
 May 23, 2022: 67, 000  Verbalize understanding  Instructed parents and guardians parents verbalized
cells/mm3 regarding measures to to put away sharp objects within understanding
prevent bleeding patient’s reach. regarding
episodes. Rationale: To reduce risk of injury measures to
 Advised parents to not offer prevent bleeding
Long Term: patient any dark-colored foods. episodes.
After 8 hours of nursing Rationale: To avoid confusion of  The patient showed
intervention, the patient will be healthcare provider by altering color of no signs of
able to: vomitus, urine and/or stool. bleeding within
 Show no signs of  Instructed parents to use soft the shift.
bleeding episodes bristle brush to patient.
within the shift. Rationale: To reduce risk of injury to
oral mucosa and skin which leads to
bleeding.

Collaborative:
 Refer patient to a Medical
Technologists.
Rationale: To monitor patient’s
platelet count through blood samples
collected.
 Refer patient to his attending
physician.
Rationale: If bleeding noted, notify the
physician to get patient checked and
monitored.
 ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS EVALUATION
Subjective Date: Altered tissue perfusion Short Term: Independent: Goals met as evidenced by
“Sige rani siya ug puyo related to insufficient After 2 hours of nursing  Encouraged the patient to the following
mag dula saiyang Ipad” as hemoglobin and intervention, the patient will be elevate the legs at the heart manifestations:
verbalized by the mother. hematocrit. able to: level, never above the level of  The patient was
 Identifies necessary the heart. able to identify
Objective Data: lifestyle changes. Rationale: Raising extremities above necessary lifestyle
 Hemoglobin test  Exhibits growing the heart level might slow arterial changes.
results: tolerance to activity. blood flow and therefore diminish  The patient
 May 21, 2022:  Verbalizes normal perfusion to the feet. exhibited growing
6.5 g/dL sensations and tolerance to
 May 23, 2022: movements as  Encouraged the patient to activity.
12.1 g/dL appropriate. exercise and increase gradually  The patient
 Engages in behaviors or at the patient’s tolerance level. verbalized normal
 Hematocrit test actions to improve Rationale: Frequent exercise helps sensations and
results: tissue perfusion. build collateral circulation. Collateral movements as
 May 21, 2022: circulation is the development of appropriate.
19.5 gm% Long Term: smaller vessels that increase  The patient was
 May 23, 2022: After 8 hours of nursing circulation in the compromised area able to engage in
37.3 gm% intervention, the patient will be that is occluded. behaviors or
able to: actions to improve
 White blood cell  Show no further  Provided warm blankets and tissue perfusion.
count: worsening/repetition encourage to keep extremities  The patient
 May 21, 2022: of deficits. warm by wearing socks and showed no further
4,800 slippers. worsening/repetiti
cells/mm3 Rationale: Cold temperatures cause on of deficits.
 May 23, 2022: vasoconstriction, hence restricting
5,200 cells/mm3 blood flow.

 Encouraged patient to change

positions at least every two
hours.
Rationale: Frequent position changes
help prevent stasis in the circulatory
system.
Collaborative:
 Refer patient to Medical
Technologist .
Rationale: To monitor patient’s
hemoglobin and hematocrit results
through blood samples collected.
 ASSESSMENT DATA
Subjective Data:
“Nag hubag iyang kamot
kung aha iyang dextrose
dapit” as verbalized by the
mother.
Objective Data:
 Noted redness and
swelling of IV insertion
site.
NURSING DIAGNOSIS GOALS AND OBJECTIVES
Risk for infection related to viral Short Term:
illness and ongoing After 1 hour of nursing
chemotherapy. intervention, the patient will be
able to:
 Demonstrate ways to
prevent spread of
infection.
 Demonstrate a
meticulous hand
washing technique.
Long term:
After 8 hours of nursing
intervention, the patient will be
able to:
 Remain free of
infection.
NURSING INTERVENTIONS
Independent:
 Encouraged hand
hygiene and explain
importance of proper
hand washing.
Rationale: Hand washing is
the single best way to
prevent infection.
 Assessed patient’s
vital signs and signs of
infection.
Rationale: Vital signs are
importance markers of
infection. Other signs can
help raise suspicion so tests
can be conducted to
confirm the presence of
infection.
EVALUATION
Goals met as evidenced by the
following manifestations:
 The patient
demonstrated ways to
prevent spread of
infection.
 The patients
demonstrated
meticulous hand
washing technique.
 The patient remained
free of infections.

 Encouraged intake of
protein-rich foods and
encouraged a
balanced diet.
Rationale: Proper nutrition
and a balanced diet
support the immune
systems’ responsiveness
and enhance the health of
all the body’s tissues.
Adequate nutrition enables
the body to maintain and
rebuild tissues and helps
keep the immune system
functioning well.
Collaborative:
 Refer patient to his
attending physician.
Rationale: If symptoms of
infection is noted, inform
physician directly to get
checked.