ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fluid volume Intestinal obstruction Short term: Independent:

“ Pengeng tubig tuyong tuyo deficit related occurs when a  After 2 hours  Kepp the  To promote After 1 day of nursing
na lalamunan ko as verbalized to abnormal blockage obstructs the of nursing patient in pulmonary intervention the
by the patient” loss of normal flow of intervention semi-fowler’s ventilation client
gastrointestin contents through the patient position  To see if Feeling on his or her
Objective: al fluids. intestinal tract. feeling  Look for their a Discomfortabity will
 Pale complexion Obstruction of the becomes sign’s of sudden loss Become comfortable.
 Dry mouth intestine causes the to comfortable. dehydration of fluid
 Dry skin become vulnerable to  After 1 hour  Monitor V/S  To see if After 1 day of
 Pain scale is 8/10 ischemia. The nursing  Monitor there is nursing intervention
V/S taken: intestinal mucosal intervention Intake other the patient
BP: 110/70 barrier can be the patient and Output complicatio verbalized the
TEMP: 36.3 damaged, thus pain scale  Health n information about his
PR: 94 allowing intestinal will Teaching  To observe or her disease.
RR: 21 bacteria to invade the decreased to about the the fluid
intestinal wall and 4/10 disease balance of
causing fluid Long Term: Dependent: the patient
exudation, which  After 3 days  Maintain the  To orrient
leads to hypovolemia of nursing client in NPO the patient
and dehydration. intervention as ordered about the
About 7 L of of fluid the fluid  Insertion of disease
per day is secreted imbalance of NGT as Dependent:
into the small the patient ordered  To examine
intestine and stomach will become  Maintain the further the
and ussually stable. IV therapy as obstruction
reabsorbed. During ordered  To
obstruction however,  Administer decompress
fluid accumulates, analgesic, the bowel
causing abdominal broad  To maintain
distension and spectrum the fluid
pressure on the anti-biotic as balance of
mucosal wall, which ordered the patient
can leads to  For pain
peritonitis and
perforation.
Obstructions can be
partial and complete/
the most common
type of intestinal
obstruction in one of
the small intestine
from fibrous adhesion.