REBOCA, CRISTELLE JOY M.

BSN 1-3 GROUP 1

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Hyperthermia as After 4-6 hours of Independent: For the patient to be The patient’s
The patient stated that evidence by interventions, the Remove linens, provide more comfortable and temperature decreased
she has a temperature temperature of 38.5°c. patient will maintain necessary circulating air vitsl signs for more to normal range. Goal
of 38.5°c. core temperature within using a fan, provide oral accurate indication of met
normal range. hygiene and monitor core temperature
vital signs.

Objective:
The patient has
temperature of 38.5°c as Dependent:
stated in the situation.
Administer the medicine
and exact dosage.

Reduces fever and

treats underlying cause.

Interdependent:
Administer the For fast recovery.
prescribed medication.
ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Wound infection as After 2-4 hours the pain Independent: To decrease the level of He patients was relieved
evidence on the right will relieved from pain or infection. and finally stop the flow
The patient says that the foot and stated as will not feel pain and to Clean the wound of the of infection. Goal met.
wound hurts. patient.
he/she walk in the decreased the level of
protuding nail. infection.

Dependent:

Physician will administer To prevent spreading of

the medication. infections.

Objective:
Interdependent:
You can see that the
patient has wound. Administer the To reduce the pain and
prescribed medication. help to stop the
infection.
 ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Inefective airway After 4 hours of nursing Independent: For the patient to be The client has been able
The patient report that clearance as evidence of interventions, the client Give the patient water if more comfortable and to maintain airway
he/she has able to expectorate sputum will be able to maintain needed,and Monitore reduce the hardship of patency. Goal met.
expectorate sputum. airwaypatency. vitalsign. breathing, and also for
the vital signs-to obtaine
baseline data.

Objective:
Dependent:
The patient has lung
crackles and expectorate Administer the medicine To clear stop the lung
sputum. and exact dosage. crackle and provide
more efective airway.

Interdependent:
Administer the Helps to reduce
prescribed medication. inefective airway and
lung crackle.