ASSESSMENT NURSING PLANNIN NURSING RATIONALE EVALUATIO

DIAGNOSIS G INTERVENTION N
S: “3 beses siyang Diarrhea r/t After 3 1. Observe and >Helps differentiate After 3 days
dumumi sa presence of days record stool. individual disease and nursing
ngayon tapos toxins as nursing assess severity of intervention
matubig , as manifested interventio episode. the goal was
verbalized by the by frequent n the partially
patient’s mother. elimination patient 2. Identify foods >Avoiding intestinal met.The
of mushy mother will and fluids that irritants promotes patient’s
O: stools. be able to: precipitate intestinal rest. mother
>increased bowel diarrhea. verbalized a
sounds/peristalsi >report mushy stool
s
reduction 3. Monitor Input >Provides information and less
>changes in stool
in and Output. about overall fluid frequent of
color
frequency balance, renal function defecation.
>frequent and
of stools and bowel disease
often severe
mushy stools. >return to control, as well as
normal guidelines for fluid
consistency replacement.

4. Observe >Indicates excessive

excessively dry fluid loss.
skin and mucus
membranes.

COLLABORATIVE:

6. Administered >Maintenance of bowel

parenteral fluids. rest requires alternative
fluid replacement loss.

7. Monitor > Determines

Laboratory replacement needs and
studies effectiveness of therapy
fluid loss from
intestines.

8. Administered >Reduces fluid loss from

medications as intestines.
indicated.

9. administered >Electrolytes are lost in

electrolytes. large amounts with
denuded, ulcerated area
and diarrhea can also
lead to metabolic
acidosis through lose of
 bicarbonate.
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTI
ON
S: No verbal cues Imbalanced At the end of 3 >Determine >All factors At the end of 3
noted. Nutrition: Less days nursing client’s ability that can affect days nursing
than body intervention to chew, ingestion intervention
O: requirements the patient will swallow and and/or the goal was
r/t excessive be able to: taste food. digestion of partially met.
>loss of weight fluid loss and nutrients. The patient’s
with adequate malabsorption >Demonstrate mother
food intake as manifested behavior, >Ascertain >To determine verbalized that
>muscle by poor skin lifestyle understanding informational the patient
weakness turgor, muscle changes to of individual needs of client. demonstrate
>Hyperactive
wasting,and regain and/or nutritional to regain
bowel sounds
sunken maintain needs weight.
>poor muscle
fontanels and appropriate
tone
WT= 1.8 kg weight. >Discuss eating >To appeal to
Wt= 1.8 kg
(<2500g) (<2500G) habits, client’s
>poor skin turgor including food likes/dislikes
>muscle wasting preferences,
>sunken intolerances/a
fontanels versions.

>Assess drug >That may be

interactions, affecting
disease effects, appetite, food
allergies, use intake, or
of laxatives absorption.
and diuretics.

>Evaluate >That can

impact of affect food
cultural, ethnic choices.
or religious
desires and
influences.

>Assess >To
weight; established
baseline
parameters.

>Note age, >Helps

body build, determine
strength, nutritional
activity/rest needs.
 level, etc.

>Consult >To implement

dietician/ interdisciplinar
nutritional y team
team, as management.
indicated.

>Use flavoring
agents

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTI
ON
S: “Akala ko Knowledge At the end of 3 >Determine >Individual A the end of 3
normal lang na deficit regarding days nursing patient’s may not be days nursing
magtae siya, condition, intervention mother physically, intervention
nung tatlong prognosis, the patient’s ability/readin emotionally, the patient’s
araw na siyang treatment self- mother will be ess and or mentally mother was
nagtatae saka care and able to: barriers to capable at able to:
lang naming discharge needs learning. this time.
dinala sa as r/t >Participate in >Participated
hospital, as unfamiliarity learning >Provide >To prevent in the learning
verbalized by with resources process information overload. process.
the patient’s
and information relevant only
mother.
misinterpretation >Verbalize to the >Verbalized
understanding situation. understanding
O:
of of the
>Inappropriat condition/dise >Provide >Can condition and
e ase process positive encourage treatment of
/ exaggerated and treatment. reinforcement continuation her son.
behaviors . of efforts.

>Inaccurate >Differentiate >Identifies

follow-through “critical” information
of instruction content from that can be
“desirable” addressed at
content. a later time.

>State >To meet

objectives learner’s
clearly in needs.
learner’s
terms.

>Involve with >Provides

others who role model
have same and sharing
problems/nee of
ds/concerns. information.

>Provide >Clarifies
mutual goal expectations
setting and of teacher
learning and learner.
contracts.

>Provide >Reinforces
written learning
information/g process,
uidelines and allows client
self learning to proceed at
modules for own pace.
client to refer
to as
necessary.