BSN 2 Sec 3 Grp B

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: Complicated grieving STO: Dx: STO:

is a maladaptive
"Hindi pa din ako process that occurs Within 8 hours of  Assess patient’s position in  Accurate baseline data (Goal Met)
makapaniwala sa when grief is intensified effective nursing grieving process. are required to plan
pangyayare ". interventions, the accurate care. Within 8 hours of
to the degree that the effective nursing
person is patient will be able to:
Objective:  These areas may be interventions,
overwhelmed,  Observed patient’s activity
a) Demonstrate neglected because of the patient
 Mood is becomes stuck in one adaptive level, sleep pattern, the process of grieving recognized the
dysphoric phase of grieving an grieving appetite, and personal and associated impact/effect
and tearful demonstrate excess behaviors and hygiene.
at times, but depression. Sleep of the grieving
prolonged emotional evidence of
client is progression patterns may be process and
response to a disrupted, leading inquire proper
responsive towards
and significant loss. to fatigue and further help.
resolution.
cooperative. b) Discuss any failure to cope with
 Pre orbital SOURCE: hard/angry distress. Patient may
puffiness. Medical Surgical feelings about require support in LTO:
 Staring Nursing, Brunner and the loss of her
distress meeting physical needs
Suddarth’s, Volume 1, baby.
c) Recognize the and may need (Goal Met)
page 987, 10th edition. assurance that it is
impact/effect
Nursing Diagnosis: of the grieving acceptable to resume Within 24 hours
process and with usual activities.Pain of effective
Complicated inquire proper nursing
can limit the patient's
grieving related to help. interventions,
ability to participate in
death of a embryo, the patient’s
self-care and function
evidenced by mood will be
difficulty of sleeping, back to normal,
dysphoric/tearful
mood, anorexia, LTO: daily activities Staring distress
and depression. independently. will be relieved,
Within 24-48 hours of Sleep will be
effective nursing back to normal.
interventions, the
patient will:

a) Participate in  Assessed ability to perform

self care activities of daily living.  Help conserve energy
activities of
and assist in daily
daily living activities until client can
(ADLS) independently do it
b) Look
toward/plan for
 Assess severity of
future, one at a depression.  Patient/couple may
time. detach themselves and
c) Sleep having problem making
adequately. Tx: decision.
d) Staring distress
 Encouraged client to “cry
will be relieved.  Grief is work and is best
out” grief to and talk
e) Mood will back treated as an active
about feelings of anger,
to normal process in which the
sadness, and guilt.
bereaved expresses
and feels the grief.
Expression of guilt or
anger is necessary for
progressing through the
grieving process and
feeling better.
 Help client recognize that
although sadness will  The sadness associated
with sorrow is
 occur at intervals for the
rest of her life, it will
become bearable.
 Strengthen the patient’s
efforts to go on with his or
her life and normal routine.
Edx:
 Encourage client to make
choices about daily living
and the home
environment that
acknowledge the loss
 Encourage client to
interact with the support
system at defined intervals.
 Encouraged verbalization
of feelings
permanent, but as the
grief resolves, there can
be times of satisfaction
and even happiness.
 Allow the patient and
family to feel that they
are enabled to do this
by supporting them.
 Helping with grief work
allows client to accept
reality of loss and realize
that grieving is a healthy
response.
 Regular contact with
support systems allows
for regular expression of
feelings and grief
resolution.
 Help the bereaved to
recognize, actualize,
and accept the loss
ASSESSMENT:
1. Focus on your Nursing Diagnosis (Subjective and Objective cues should ALL be align with your problem)
2. Subjective data (preferably verbalization from the patient and must be in an open and close quotation otherwise if it is coming from the mother
or any significant other, it must be categorize as subjective data from a secondary source or an objective data [if it can be perceived by the
senses, verified by another person observing the same patient, and tested against accepted standards or norms] from a secondary source).
3. Objective data (start with the most obvious observation that is related to your nursing diagnosis to the less obvious, followed by abnormal vital
signs that are related to your problem and any laboratory results that are relevant to your problem)
4. For Nursing Diagnosis, use the 3-Part Statement: PES Format (Problem + Etiology + Signs and Symptoms) Three parts are joined together by
“related to” or “associated with” and “as manifested by” or “as evidenced by”
EXPLANATION OF THE PROBLEM:
1. Should be in paragraph form, it’s just like doing your pathophysiology but explaining in detail how the problem arise in relation to your objective
data and other signs and symptoms manifested by the patient that are related to your problem.
2. DO NOT FORGET to indicate your source as a basis in coming up with your explanation of the problem.
OBJECTIVES:
1. Must follow the concept of SMART (Specific, Measurable, Attainable, Realistic and Time bound).
 2. STO (Short Term Goal). In theory it covers your acute care (till 6 months). But for our requirement we measure our STO within the shift (0 – 8 hours).
A better parameter would be using ranges of time depending on the planned activities.
3. LTO (Long Term Goal). In theory it covers your chronic care (6 months and above). But for our requirement we measure our LTO within the first day
to the third day or one rotation (24 – 72 hours). A better parameter would be using ranges of time depending on the planned activities.
NURSING INTERVENTION:
1. Dx (diagnostics) should be based on your SUBJECTIVE and OBJECTIVE DATA.
2. Tx (therapeutics) should be arrange as ICDS (Independent nursing function, Collaborative [other health-care professional aside from the
physician], Dependent nursing function [physician/doctor], Supportive [Significant others, clergy/priest, and non-health care professional]
3. Edx (educative) should be based on the most needed by the patient that is relevant to the nursing diagnosis. (you can also base it on your STO
and LTO if there are educative goal)
RATIONALE:
1. It must be aligned with your nursing intervention and relevant to the case of you patient.
2. For the administration of medication, your rationale should be the indication of the drug in relation with the patient’s case.
EVALUATION/ EXPECTED OUTCOMES:
1. Evaluation for ACTUAL PROBLEM and your NURSING INTERVENTION should be past tense.
2. EXPECTED OUTCOME for POTENTIAL PROBLEM and your NURSING INTERVENTION should be future tense.
3. Should evaluate (GOAL MET, GOAL NOT MET or GOAL PARTIALLY MET) accurately and should be supported by results from your STO and LTO.
4. For expected outcomes (GOAL MET IF, GOAL NOT MET IF or GOAL PARTIALLY MET IF), and give parameters for the IF.
5. Should discuss or make recommendation/s for goal not met and partially met.

Always remember that NURSING PROCESS is SYSTEMATIC, PATIENT-CENTERED, GOAL-ORIENTED AND DYNAMIC.