ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Risk for Injury SHORT TERM Determine the To assess SHORT TERM
Subjective: “natatakot related to GOAL: degree of functional GOAL:
ako baka mahulog sya complex After 4 hours immobility in ability After 4 hours
pag-inaatake sya” as seizures of nursing relation to of nursing
verbalized by the secondary to intervention functional level intervention
mother of the patient CNS Infection the patient scale the patient
and guardian and guardian
Objective: will develop Assess To assess are able to
T: 36.8 and follow risk nutritional functional develop and
PR: 99 control status ability follow risk
RR: 24 strategies by control
O2 sat:98% verbalization Loosen For patient strategies by
BP: 100/80 of constrictive comfort and verbalization
understanding. clothing for easy of
(+) seizure access of understanding.
(+) right lower LONG TERM changing cloth
extremity weakness GOAL: LONG TERM
(+) Muscle Dystrophy After 8 hours Maintain bed For patient GOAL:
of the Upper and of effective in lowest safety After 8 hours
Lower Extremities nursing position, raised of effective
intervention, side rails and nursing
GCS 15 the client will wheels locked intervention,
have no the client has
incidence of Kept patient on To give no longer
injury, causing one side sufficient o2 incidence of
events such as injury, causing
falls. Eliminate To promote events such as
safety hazards safety and falls.
and protect maintain
the client from privacy of the Goal met
exposure patient.
anytime nor
during seizures
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATIO
N N
SHORT Assess Different level of SHORT
Subjective: Ineffective TERM patient’s anxiety will affect TERM
“ayaw ko na mama, coping/ GOAL: anxiety the coping GOAL:
Mama naman e” Anxiety After 4 mechanism of After 4
“Lord, tulungan mo related to hours of client hours of
po ako” as verbalized uncertainty nursing nursing
by the patient and fear of interventio Acknowledgement intervention
CNS n the s of patient’s the patient
Objective: infection patient will Acknowledge feelings validates was able to
T: 36.8 secondary be able to awareness of the feelings and show some
PR: 99 to complex know some patient’s communicates techniques
RR: 24 seizures, as techniques anxiety acceptance of to lessen
O2 sat:98% evidenced to lessen such anxiety such
BP: 100/80 by anxiety as deep
verbalizatio such as Instruct to do This may help breathing
 Guarding n of worry deep deep patient to relax exercises.
behavior breathing breathing
 Cries exercises. LONG TERM
 Fear Provide Helps the client to GOAL:
 Anxiety LONG accurate identify what After 8
 Muscle TERM information reality is based hours of
Dystrophy of GOAL: about the nursing
the Upper After 8 situation intervention
and Lower hours of the patient’s
Extremities nursing Establish a An ongoing anxiety was
 Irritability interventio working relationship lessen and
 Twitches/ n the relationship establishes a basis become
ticks patient’s with the for comfort in relaxed
 Dysphagia anxiety will patient communicating
 seizure be much through anxious feelings. (-) cries
lessen and continuity of (-) Fear
become care, maintain (-) guarding
relaxed a calm behavior
manner while
interacting Goal
with the partially
patient Met