NCP 1

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Fluid volume After 8 hours of Independent: After 8 hours of

Vital sings: deficit related to proper nursing -Monitor vital signs -To get a baseline data and to proper nursing
-BP (140/90) dehydration as interventions, detect further complications interventions, the
-RR (14 bpm) evidenced by the patient will patient:
-PR (60 bpm) muscle weakness gain strength -Assess skin turgor and -To assess the severity of -gained strength
-Temp (38 and dry mucous and have a oral mucous membranes dehydration and to give proper -balanced fluid
degrees Celsius) membranes balanced fluid especially in the sternum interventions like fluid input and output
input and output or inner thighs replacements -skin turgor <2
-cachectic Scientific seconds
-skin turgor >2 explanation: -Strictly monitoring of -Having a balanced input and
seconds The patient’s input and output output allows the metabolic GOAL MET
-dry mucous sodium, activities of the body to
membranes creatinine and function normally
-weak looking chloride level are
-Urge to drink the -Normal fluid intake can help
appearance abnormally high
prescribed amount of fluid hydrate the patient and prevent
-muscle weakness which contribute
if the patient can tolerate dizziness and weakness
to the dehydration
-Sodium level- of the patient. oral fluids and provide
167 mmol/L straw as much as possible
Having these
-Chloride level- three in an
-Asses mental alteration -Dehydration can cause
125 mmol/L abnormal level
such as confusion or slow impaired mental status. It is to
-Creatinine level- can affect the
responses by asking the assess the patient’s mental
1.8mg/dL patient’s kidney
patient about his/her status
to function well
personal information
that’s why the
-Explain the patient’s -It is important to know what
patient has fluid
condition to the relatives exactly the condition of the
 volume deficit. and try to explain it to the patient and to prepare for
Symptoms of patient as much as possible danger/compilations
hypernatremia, possible
hyperchloremia, -Patients with heart disease
and -Ask the relatives whether and older patients are
hydronephrosis the patient has any history susceptible to the development
including of heart disease before of pulmonary edema.
dehydration and initiating parenteral
weakness, which administration
are the main
symptoms the Dependent: -To give fluid replacement for
patient -Give IV fluid therapy as dehydration
experiences ordered by the primary
care provider
-To provide proper nutrition
-Provide Partial Parenteral especially if patient has a poor
Nutrition as prescribed by oral intake or cannot tolerate
the physician solid foods

NCP 2
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Imbalanced After 12 hours of Independent: After 12 hours

nutrition: less than proper nursing -Assess the patient’s eating -Determining the eating of proper
-Weight 35kg body requirements interventions, the pattern pattern will provide what nursing
-Cachectic related to decreased patient will gain proper interventions might interventions,
-Weak looking oral intake as weight and be helpful and aid in client had
appearance evidenced by restore her determining nutritional risk increased body
-Muscle weight loss strength and worsening nutritional weight and
weakness status. gained strength
Scientific -Assess the patients food -To determine the degree
Explanation: choices by taking nutritional of malnutrition accurately
Decreased oral history with the participation and metabolic energy GOAL MET
intake can cause of the relatives needs.
weakness and -Determine the patient’s
weight loss since BMI. Monitor the weight -Determining the weight of
only the food can with the same time each day. the patient daily is very
make our metabolic necessary to know if the
activities in the interventions given are
body to function helpful or not to the
appropriately. patient. BMI to find out if
-Give pleasant and quiet her weight is appropriate to
environment its height and age.
-A pleasing and quiet
environment helps in
-Provide high caloric foods decreasing stress and is
and carbohydrate foods more favorable for eating
-To gain weight instantly
and to gain strength
because carbohydrates is a
macronutrient that can be
-Promote proper positioning consumed in high amount
-To prevent aspiration after
eating. Usually, semi
-Provide oral hygiene and fowler’s position
dentition -Good oral hygiene has a
-Assist the patient during big impact in appetite
mealtime -Assistance will help the
patient eat the prescribed
amount of food and to
Dependent: avoid spilling and excess
-Provide Partial Parenteral of food
Nutrition as prescribed by
the physician -To provide proper
nutrition especially if
patient has a poor oral
-Give IV fluid therapy as
intake or cannot tolerate
ordered by the primary care
solid foods
provider
-To give fluid replacement
for dehydration
Collaborative:
-Collaborate with the
dietician about the condition
of the patient -For further management
of the problem
NCP 3

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Chronic confusion After 8 hours of Independent: After 8 hours of

“Sino ka? Bakit nyo related to history of proper nursing -Test the patient’s -Patients with proper nursing
ako dinala dito? dementia as interventions, the mental ability by chronic confusion interventions, the
Wala naman ako evidenced by patient will have an asking her personal has a high tendency patient has an
sakit” as verbalized impaired verbal improved verbal information to forget their improved verbal
by the client communication communication and persona information communication and
-decreased social perform more social -Provide a calm -Any extraneous started to participate
activities Scientific activities environment noise and stimuli can more in social
Explanation: be misinterpreted by activities
Objective: Dementia is a mental the confused patient.
-confusion disorder that can lead -Speak in a calm and -Patient might think GOAL MET
-impaired verbal to alzheimer’s sweet voice that you are angry if
communication disease. Having a you speak in a high
-malnutrition history of this and load voice
condition can -Promote reality- -Orientation to one’s
triggered the mental oriented environment can
function of brain as relationships and help increased trust
we aged that why the environment by to someone
patient experienced displaying clocks,
impaired verbal calendars, and
communication that persona items -This can help
causes confusion. -Talk to the patient reduce anxiety
with a caring and
friendly attitude and
talk calmly and
slowly -To completely
-Allow the relatives understand what is
to orient the patienthappening and to
about current news promote degree of
and family events safety
and talk to her more -To promote
often independence and
sense of
-Advice the patient responsibility
to participate in
socialization groups

Dependent: -To help the mental

-Administer ability to function
medication as well
prescribed by the
physician

Collaborative: -For further

-Collaborate with the management of the
psychiatrists about problem
the problem