Adamson University

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Diarrhea related Short Term: 1. Establish rapport 1. To gain patient’s trust Short Term:
 Verbalization of to presence of After 2-3 hours of 2. Assess general condition 2. For baseline data After 2-3 hours of
pain with a scale toxins as nursing and vital signs nursing interventions,
of 6/10 on the manifested by interventions, the 3. Observe and record stool 3. Helps differentiate the patient shall have
abdominal area frequent patient will frequency, characteristics, individual disease and verbalized
amount, and precipitating assesses severity of
elimination of verbalize factors. episode. understanding of
Objective: mushy stools. understanding of 4. Auscultate abdomen 4. For presence, location, and causative factors and
Patient manifested: causative factors characteristics of bowel rationale for
 Hyperactive and rationale for sounds treatment regimen.
bowel sounds treatment regimen. 5. Discuss the different 5. For patient education
 Audible causative factors and
borborygmi Long Term: rationale for treatment Long Term:
 Passage of loose After 1-2 days of regimen After 1-2 days of
liquid watery nursing 6. Restrict solid food intake 6. To allow for bowel rest and nursing interventions,
stools for more interventions, the reduce intestinal workload the patient shall have
than 3 times patient will 7. Provide for changes in 7. To allow foods/substances reestablished and
reestablish and dietary intake that precipitate diarrhea maintained normal
maintain normal 8. Limit caffeine and high- 8. To prevent gastric irritation pattern of bowel
pattern of bowel fiber foods and so as fatty functioning AEB
functioning AEB foods passage of semi-solid
passage of semi- 9. Promote use of relaxation 9. To decrease stress and stools
solid stools technique anxiety
10. Encourage oral fluid intake 10. For fluid replacement
of fluids containing
electrolyte
11. Recommend products like 11. To restore normal flora
yogurt and cultured milk
12. Emphasize importance of 12. To prevent spread of
hand washing infectious diseases

College of Nursing
 Name of Patient: __________________________________________ Date: __________

Submitted by: Lorie May V. Guillang

Adamson University
College of Nursing
Name of Patient: __________________________________________ Date: __________
Submitted by: Lorie May V. Guillang

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: (none) Deficient fluid Short term: 1. Establish rapport 1. To gain patients trust Short term:
volume RT After 4 hours of After 4 hours of
Objective: excessive losses nursing 2. Monitor and record VS 2. To obtain base line data nursing interventions,
through normal interventions, the the patient shall have
 passage of routes AEB patient will report 3. Assess patient’s condition 3. To be aware of the patient’s reported
loose watery frequent passage understanding of condition and feeling understanding of
stool of loose watery causative factors causative factors for
 vomiting stool for fluid volume 4. Monitor Input & Output 4. to ensure accurate picture of fluid fluid volume deficit
 abdominal deficit balance status
cramping
 dehydration Long Term: 5. Maintain adequate 5. To prevent dehydration & maintain Long term:
 nausea After 3 days of hydration, increase fluid hydration status After 3 days of Nursing
 fatigue Nursing intake. Interventions, the
 weakness Interventions, the patient shall have
patient will 6. Provide frequent oral care 6. To prevent from dryness maintained fluid
maintain fluid volume at functional
volume at 7. Administer Intravenous 7. To deliver fluids accurately and at level AEB well
functional level fluids as prescribed desired rates. hydrated, intake is
AEB well hydrated, equal as output, and
intake is equal as 8. Determine effects of age. 8. Very young and extremely elderly normal skin turgor.
output, and normal individuals are quickly affected by
skin turgor. fluid volume deficit
 9. Restrict solid food intake, 9. To allow for bowel rest and to
as indicated reduced intestinal workload.

Adamson University
College of Nursing
Name of Patient: __________________________________________ Date: __________
Submitted by: Lorie May V. Guillang

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Readiness for Within the 8˚ shift, 1. establish rapport 1. to facilitate cooperation as Within the 8˚ shift,
Enhanced the client will well as to gain pt’s trust the client
Therapeutic maintain normal maintained normal
Regimen related health status and 2. assess the clients level 2. to assure accuracy and health status and
to normal health remain free from of understanding of completeness of knowledge remained free from
status. possible therapeutic regimen base for future learning possible
complications complications.
3. accept client’s 3. it promotes sense of self-
evaluation of own esteem and confidence to
strengths or limitations continue efforts
while working together
to improve abilities

4. help client’s needs, 4. to maintain high-level of well-

potential problems, and being
sources of stress

5. identify contributing 5. to prevent possible

factors that may need complications
to be improve now or in
the future
6. provide suggestions to 6. to broaden ideas that the pt
the pt for sources of may already have in order to
support that will help reinforce positive behaviors
reinforce enhanced
behaviors

7. take and record vital 7. to note changes that can affect

signs the pt’s condition

8. provide health 8. to promote optimum wellness

teachings such as:
 increase oral fluid
intake

 instruct proper
disposal of wastes

 emphasize the
importance of
 proper hygiene

 review the manner of

preparation and
 storage of foods

 advise to avoid eating

street foods