Assessment Nursing Scientific Planning Nursing Rationale Evaluation

Diagnosis Rationale Intervention

O-With pale Altered After 2 weeks, -Monitor vital -for baseline data Goal Partially
conjunctival Nutrition: Less the patient will signs -assess fluid and met: the patient
sac than Body demonstrate -Monitor intake electrolyte will demonstrate
-with poor Requirement behaviors or and output balance behaviors or
muscle tone related to changes to changes to regain
-weight (4.4 kls) inability to regain and or -these provide from the weight
-with poor skin absorb nutrients maintain -Instructed the S.O information of 4.4kls to
turgor as evidenced by appropriate mother with how nutrition 4.18kls
-weak and pale poor muscle tone weight regards to: could elevate
in appearance patient chances
of a foster
recovery and
wound healing
-

•Proper -to reduce

hygiene microorganism
•Proper and prevent
handwashing transmission of
diseases
-to provide
proper nutrition
•Proper needed by the
breastfeed and child
breast care

•Proper
 nutrition
-Document
patients actual
weight
 Assessment Nursing Rationale Planning Nursing Rationale Evaluation
Diagnosis Intervention

O- with Risk for After 8 hours of -Monitor vital -for baseline data Goal Partially
generalized secondary nursing signs -assess fluid and Met: the patient
desquamation infection related intervention, the - Monitor intake electrolyte will maintain
- with multiple to presence of patient will and output balance free from
lesions multiple lesions maintain free -reduce invading acquiring
secondary to from acquiring microorganism secondary
underlying secondary - Provide wound infection as
pathology infection care aseptically evidenced of
-less irritating decreasing
body cells generalized
- Cleanse the desquamation
wound with
PNSS
- Assess odor
and wound -prevent
appearance iatrogenic
- Maintain contamination
aseptic
technique; wear
mask and sterile
gloves for -reduce
physical contact pathogens in
- Keep work area environment
clean