Assessment Nursing Diagnosis Scientific Nursing Goal Nursing Rationale Evaluation

11-02-09 day explanation Intervention 11-07-09

Subjective: Risk for Short term: -Established -to gain trust from After 8 hours of
“masakit ang tiyan imbalance After 8 hours of rapport to the patient and SO NI the GOAL was
ko at nutrition ;less than NI the patient will patient and to SO -for baseline data met AEB: -the
nanghihina,kaso body start to -assessed vital -for comparative patient will start to
bawal pa naman requirements r/t demonstrate signs and note baseline data demonstrate
akong kumain” inability to ingest behavior, lifestyle presence of flatus behavior, lifestyle
Objective: nutrients and changes to regain -assessed weight, -to know what changes to regain
-Vital signs intestinal weight AMB: age, body built and kind of weight
T-36.9 dysfunction -vital signs w/n strength intervention to be -vital signs w/n
PR-85 bpm normal range done normal range
RR-33cpm T-36.5-37.5 -identify clients at -to know the other T-36.9
BP-110/80 PR-60-100bpm risk for malnutrition factors of PR-85bpm
mmHg RR-16-20cpm malnutrition RR-16cpm
-with abdominal BP-90/60- -determine if the -to determine BP-120/70
pain rated as 6/10 140/100mmHg patient has the what information mmHg
-presence of -verbalization of ability to chew, will be provided to - patients
abdominal understanding of swallow and taste client verbalization of
tenderness causative factors understanding of
-on NPO for 9 when known and -ascertained -to appeal clients causative factors
days necessary understanding of desires when known and
-activity tolerance interventions individual nutritional necessary
of 7/10(criteria by -decrease needs interventions
BORG of 1982) abdominal pain -discussed the -To know if there’s -decrease
-hypoactive bowel and tenderness eating habits of the an abnormal abdominal pain
sound or -improvement on patient and peristalsis rated as 5/10 and
hypoperistalsis(3 the bowel auscultated bowel tenderness
clicks/min) sounds(7 sounds -improvement on
-body weakness clicks/min) -promoted pleasant, -to reduce anxiety the bowel
-ability to do -decrease body relaxing and to enhance sounds(2
ADL’s with weakness environment intake clicks/min)
maximal Long term -provided oral care -to prevent Long term
assistance After 5-6 days of before and after infection After 5 days of NI
-absence of flatus NI the patient will meals(after NGT is the GOAL was
-muscle strength demonstrate removed partially met AEB:
RLE-3/5 behaviors to -encouraged -decrease -patient
LLE-3/5 regain and moderate intake of hypertonicity of demonstrated
RUE-3/5 maintain fat and low intestinal contents behaviors to
LUE-3/5 appropriate weight carbohydrates(after prevent regain and
BMI-22.46(near to AMB: NGT is removed) maintain
underweight) -absence of -limit fiber/bulk and -because it may appropriate weight
abdominal pain fluids 1 hour prior to lead to early -start to ingest
and tenderness meal(after NGT is satiety nutritious foods
-absence of body removed) -still with slight
weakness -prevent or -may have a abdominal pain
-ability to do minimize negative effect on -still with body
ADL’s with unpleasant appetite/eating weakness
minimal odors/sights -ability to do
assistance ADL’s w/ minimal
-presence of flatus Collaborative assistance
-activity tolerance -administered -it will help to -presence of flatus
of 2-3/10 intravenous fluids prevent and -activity tolerance
-muscle strength as prescribed maintain fluid and of 3/10
of electrolytes -muscle strength
balance of
RLE-5/5 - RLE-4/5
RUE-5/5 Biomix(incorporated -vit.B12 deficiency RUE-4/5
LLE-5/5 to D5LR 1L for * from inadequate LLE-4/5
LUE -5/5 hrs.) and diet, pernicious LUE -4/5
-improvement on multivitamins(OD) anemia or other -BMI-23.5
his BMI(inc of 2) GI disease and -verbalization of
inadequate the pt that there is
secretion of an improvement
intrinsic factior
-keep patient on -to prevent further
high calorie ,fat and imbalance
protein diet with nutrition
vitamin
supplements as
indicated by his
condition
-consult -to implement
dietician/nutritional interdisciplinary
team,as indicated team
management
Assessment Nursing Diagnosis Scientific Nursing Goal Nursing Rationale Evaluation
10-28-09 Explanation Intervention
Subjective: Ineffective tissue Short term goal: -Establish rapport -for a good nurse- After 8 hrs of NI
“masakit dito sa perfusion After 8 hrs of NI patient relationship the goal was met
tiyan ko,pati ung (gastrointestinal) the patient -Monitor V/S and -that would indicate AEB:
dibdib r/t decrease demonstrate also include I&O that peritonitis - patient
ko,nanghihina oxygen carrying improvement on monitoring subsides r worsen demonstrated
ako” capacity of blood ventilation and -to check if there is improvement on
Objective: due to blood adequate a sign of ventilation and
-Vital Signs: loss/hypovolemia oxygenation hypovolemic adequate
T-38.5 of tissues AMB: shock(dec BP) oxygenation
PR-105bpm -improvement of -ascertain -to assess for of tissues
RR-15cpm vital signs(within location/type/ further -improvement of
BP-110/80 normal range) intensity/timing of complication vital signs
-abdominal T-36.5-37.5 abdominal pain .(midepigastric pain T-37.4
pain(6/10) or PR-60-100bpm ff meals and lasting PR-110bpm
tenderness RR-12-20 several hours RR-17cpm
-restlessness BP-90/60- suggests BP-100/70mmHg
-pale and weak in 140/90mmHg abdominal angina -there is an
appearance -improvement on reflecting improvement on
-pale and dry lips pain and atherosclerotic pain rated as
-recurrent report tenderness felt by occlusive dse. (5/10) and feeling
of pain the pt on his -elevate head of -to promote lung of tenderness on
-body weakness abdomen the bed/position expansion the abdomen
-poor skin -minimal client -it will provide -minimal
turgor(1-2 secs) restlessness appropriately airway adjuncts restlessness
-use of accessory -minimal body and suctions as -minimal body
muscles weakness indicated to weakness
-capillary refill of -minimal paleness maintain airway -minimal paleness
2-3 seconds -minimal paleness -patient can also -this position -minimal paleness
-Muscle strength and dryness of be place on the decreases tension and dryness of lips
RUE-3/5 lips side w/ knes on the abdominal -minimal verbal
LUE-3/5 -minimal report of flexed organs report of pain
RLE-3/5 pain -maintain -for mobilization of -improvement of
LLE-3/5 -less use of adequate I&O secretions but skin turgor(1-2
-decrease hgb accessory avoid fluid overload secs)
level(10mg/dL) muscles -keep environment -to reduce irritant -less use of
-improvement on allergen and effect of dust and accessory
capillary refill of pollutant free chemical on muscles
pt(from 2-3 secs airways -improvement on
to 1-2 secs) -provide capillary refill of
After 3-4 days of psychological -to reduce anxiety pt( 1-2 secs)
NI the patient will support
demonstrate -encourage freq. After 3 days of NI
improved position -promotes optimal goal was partially
ventilation and changes(after chest expansion met AEB:
adequate NGT is removed) and drainage -the patient will
oxygenation of and deep secretions demonstrated
tissues AMB: breathing improved
-vital signs within exercises and its ventilation and
normal range importance adequate
T-36.5-37.5 -instructed to oxygenation of
PR-60-100 avoid over -to conserve and tissues
RR-12-20 exertion limit oxygen -vital signs within
BP-90/60- -reinforce need for demand normal range
140/90 adequate rest -to decrease T-37.2
-absence of pain especially after dysnea and PR-89bpm
-absence of meals improve quality of RR-15cpm
restlessness life and to BP-
- absence of pale maximize blood 120/80mmHg
ness and body flow to -absence of pain
weakness stomach,enhancing and tenderness on
-absence of -emphasized the digestion the abdomen
paleness and importance of -it improves -absence of
dryness of lips nutrition stamina and restlessness
-absence verbal reducing the work - absence of pale
report of pain of breathing ness and body
-good skin Collaborative weakness
turgor(0-1 secs) -oxygen therapy -absence of
-no use of via nasal cannula -promotes paleness and
accessory ms. and mask adequate dryness of lips
-capillary refill of oxygenation -still with verbal
(0-1 secs) -administered -it will help to report of slight
-muscle strength intravenous fluids prevent and pain on the
RUE-5/5 as prescribed maintain fluid and abdomen
RLE-5/5 electrolytes -good skin
LUE-5/5 balance turgor(0-1 secs)
LLE-5/5 -no use of
-hgb level within -Tranfused(Whole -to treat acute accessory ms.
normal range() blood and massive -capillary refill of
hemorrhage or (0-1 secs)
hypovolemic shock -muscle strength
due to hemorrhage RUE-4/5
PRBC)properly -for anemic RLE-4/5
typed and pts,surgical pts LUE-4/5
crossmatched before and after LLE-4/5
operation and -hgb level within
many cases of normal
acute blood loss range(13mg/dL)