Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Readiness for Short Term: Independent: Independent:

“ He can Enhanced
express his Knowledge as ● After 4hrs ● Assist the ● This helps to After all the
own decision Manifested by of client to frame or focus nursing
like learning Learning Nursing identify content to be interventions,
independently Independently Intervention learning learned and ways to easily
to gain more the client goals and provides a enhance the
knowledge, go will be able measurable measure to knowledge of
to the comfort to identify outcomes. evaluate the the client will
room to ways to help ● Verify the learning be identified
urinate, and client client’s process. and the
only ask for enhance his level of ● This provides knowledge of
help whenever knowledge knowledge an opportunity the client will
he wants me to easily. about a to ensure gradually
wipe his specific accuracy and increase.
buttocks and Long Term: topic. completeness
clean after he’s ● Determine of knowledge
done ● After 1 motivation base for future
defecating.” week of and learning.
nursing expectations ● This provides
intervention, for learning. insight useful in
client’s developing
needs will Dependent: goals and
be met and identifying
his ● Note information
knowledge personal needs.
will factors (e.g.,
continue to age/develop Dependent:
enhance. mental
level, ● That may
gender, impact learning
social/cultur style and choice
al of
influences, informational
religion, life resources.
experiences, ● This identifies
level of special needs to
education). be addressed if
● Determine learning is to be
any successful.
challenges
to learning: Collaborative:
language
barriers ● This provides
(e.g., client additional
cannot read, opportunities
speaks or for role
 understands modeling, skill
language training,
other than anticipatory
that of care problem-
provider, solving, and so
dyslexia); forth.
physical
factors (e.g.,
sensory
deficits,
such as
vision or
hearing
deficits,
aphasia):
physical
stability
(e,g., acute
illness,
activity
intolerance):
difficulty of
material to
be learned.

Collaborative:

● Identify
available
community
resources/su
pport
groups.
Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Risk for shock as Short Term: Independent: Independent: Short Term:
“ manifested by
epistaxis ● After 2hrs of ● Instruct ● For After 4hrs of
nursing client/SO in timely nursing
interventions ways to evaluati interventions the
the nurse will prevent on and patient was able
be conduct and/or intervent to be afebrile
health manage ion. and free of other
teaching about underlying signs of
prevention of conditions ● For infection,
nosebleed and that cause changes achieved timely
signs and shock, associate wound healing.
symptoms of including d with
shock heart shock
disease, states: Goal Met:
Long Term: injuries, heart
dehydration rate and After 3days of
After 3 days , infection. rhythm, nursing
of nursing ● Indentify respirati intervention, The
interventions reportable ons, patient
the client will signs & blood verbalized
be able to symptoms, pressure, understanding of
verbalize including pulses causative factors
understanding unrelieved and neck and purpose of
of causative pain, veins, individual
factors and unresolved temperat therapeutic
purpose of bleeding, ure, and interventions and
individual excessive so forth. medication. The
therapeutic fluid loss, patient also
interventions persistent Dependent: demonstrated
and fever and behaviors to
medication. chills, ● Enhance monitor and
change in s correct deficit
skin color complia indicated.
accompanie nce with
d by chest drug
pain. regimen,
● Assess vital reducing
signs and individu
tissue and al risk.
organ ● To avoid
perfusion. cross
contami
Dependent: nation.
● For
● Teach healing
client and
 purpose, immune
dosage, system
schedule, support.
precautions
, and
potential Collaborative:
side effects
of ● To
medication provide
s given to foods
treat rich in
underlying nutrients
conditions. ,
● Teach vitamins
client/ , and
family minerals
members need to
importance promote
of good healing
hand and
hygiene, support
clean immune
environmen system.
t, and ● To
avoiding maximiz
crowds e
when ill, systemat
especially ic
if client is circulati
immunoco on and
mpromised. tissue
● Encourage and
consumptio organ
n of healthy perfusio
diet, n.
participatio
n in regular
excercise,
and
adequate
rest.

Collaborative:

● Provide
nutrition by
best
means–
oral,
enteral, or
 parenteral
feeding,
refer to
nutritionist
or dietitian.
● Collaborate
in prompt
treatment
of
underlying
conditions
such as
trauma,
heart
failure,
infections,
and prepare
for/assist
with
medical
and
surgical
interventio
ns.