ASSESSMENT NURSING RATIONALE DESIRED NURSING JUSTIFICATIONS EVALUATION

DIAGNOSIS OUTCOME INTERVENTIONS

Subjective cues: Self-Care Deficit: Exposure to dengue After 40 hours of Independent: After 40 hours of
Patient’s mother bathing related to prone area nursing intervention, nursing intervention,
verbalized, “wala pa ko discouragement to the patient will be able 1. Monitor the 1. Monitor the the patient will be able
ya kapaliogo sang na ambulate: complete to: patient’s and patient’s and to:
hospital ko ya.” bed rest without parents’ potential parents’ potential
bathroom privileges as Aedes Egypti mosquito 1. Identify individual for self-care for self-care.
Objective cues: evidenced by unkempt bite areas of weakness measures
- Limited activity appearance secondary or needs. appropriate to age
- With complete to disease process. and developmental
bedrest without 2. Verbalize factors.
bathroom Dengue hemorrhagic knowledge of 2. Allow the patient 2. Enhances
privileges as fever grade 2 healthcare practices and parents to satisfaction, and
ordered ny the Definition: participate in increases the
doctor. Impaired ability to 3. Demonstrate planning for care likelihood that care
perform or complete techniques and when possible to will be continued
Risk Factors/ feeding, Decreased platelet lifestyle change to help ensure best after discharge
Weaknesses: bathing/hygiene, count and WBC count meet self care compliance such as from hospital.
- poor dressing and grroming, needs. bathing everyday 3. Teach the
environmental or toileting activities 3. Teach the appropriate skills
health care for oneself. appropriate skills necessary for self-
- poor physical Prone to bleeding and 4. Perform self –care necessary for self- care in the child’s
health and care infection activities within care in the child’s terms, with
- unable to take a Source: level of own terms, with sensitivity to
bath for 5 days Doenges, M. et. Al., ability. sensitivity to developmental
(2010). Nurse’s pocket developmental needs for practice,
Guide: Diagnoses, Avoid excessive 5. Identify personal needs for practice repetition, or
Wellness/ Strengths Interventions and activities that could and community repetition, or reluctance
- cooperative Rationales. (12th cause bleeding resources that can reluctance. 4. Confidence in self-
behavior edition). Philadelphia, provide assistance. 4. Provide care will enhance
- strong family F.A. Davis Company. opportunities that self-esteem.
support. Pp. 708-713. will enhance the
Noncompliance to child’s confidence
desired minimal in performing self-
activity of the client care.

Collaborative:
Complete bed rest
without bathroom 1. Review instructions 1. Provides
privileges from other clarifications,
members of the reinforcement;
healthcare team and allows periodic
Self care deficit: provide a written review by
bathing copy. client/caregiver.