ASSESMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION
Subjective: Readiness for When the systems Within the 8˚ Independent: Goal met.
“Okay na ako.” Enhanced in the body shift, the client - establish rapport - to facilitate Within the 8˚
Therapeutic respond well to will maintain cooperation as well shift, the client
Objective: Regimen related medications and normal health as to gain pt’s trust maintained
- received pt. lying to normal health treatments it status and normal health
on bed ĉ ongoing status. results to good remain free from - assess the clients - to assure accuracy status and
IVF of PNSS 1L to health. Thus, our possible level of understanding and completeness of remained free
run for 12˚ @ 850cc body is ready to complications. of therapeutic knowledge based for from
level, infusing well regain its normal regimen future learning possible
to left functioning. - it promotes sense complications.
- conscious and - accept client’s of self-esteem and
coherent evaluation of own confidence to
-ambulatory strengths or continue efforts
- ĉ non-productive limitations while
cough working together to
- ĉ good skin turgor improve abilities - to maintain high-
-ĉ good capillary - help client’s needs, level of well-being
refill potential problems,
- on soft diet and sources of stress - to prevent possible
- ĉ good appetite, - identify contributing complications
consumed all food factors that may need
served to be improve now or - to broaden ideas
- ĉ presence of in the future that the pt may
active bowel sounds - provide suggestions already have in
in the abdomen to the pt for sources of order to reinforce
- voiding freely ĉ support that will help positive behaviors
yellowish urine reinforce enhanced - to note changes
output behaviors that can affect the
- afebrile - take and record vital pt’s condition
signs - to promote
optimum wellness
- provide health
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

Dependent: - to assure that the

- to regulate IVF as body receives
ordered accurate amount of
fluids and
electrolytes
- to aid in the easy
- to give due recovery
medications - to serve as a guide
- instructed on home in doing self-
meds medication that
promotes
independence
 ASSESMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
EXPLANATION
Subjective: Risk for fluid When there is Within the 8˚ Independent: Goal met.
“Okay na ako.” volume deficit insufficient fluid shift, the client - establish rapport - to facilitate Within the 8˚,
related to intake, and will not exhibit cooperation as well the client
Objective: excessive loss of excessive fluid loss signs and as to gain pt’s trust exhibited no
- received pt. lying fluids and from vomiting, and symptoms of fluid - assess skin turgor - to note presence of signs and
on bed ĉ ongoing electrolytes diarrhea it volume deficit. and oral mucous dehydration symptoms of
IVF of PNSS 1L to indicates membrane fluid volume
run for 12˚ @ imbalance in fluid - monitor and record I -to ensure accurate deficit AEB good
850cc level, volume in which & O balance being fluid replacement skin turgor and
infusing well to left the body can’t aware of insensible therapy moist oral
- conscious and compensate by an losses mucous
coherent adequate intake of - weigh client and - to evaluate membranes.
-ambulatory water. Decreased compare with recent changes as related
- ĉ non-productive volume in the weight history to fluid status
cough intravascular -monitor vital signs - BP,RR, PR often
- ĉ good skin turgor compartment is increases when
-ĉ good capillary called either fluid deficit or
refill hypovolemia. excess is present
- on soft diet Because water - encourage increase - to facilitate
- ĉ good appetite, moves freely oral fluid intake hydration
consumed all food between the - note increase
served compartments, lethargy, - electrolyte
- ĉ presence of extracellular fluid hypotension, and imbalances may be
active bowel deficit causes muscle cramping present
sounds in the intracellular fluid
abdomen deficit (cellular Dependent:
- voiding freely ĉ dehydration), - regulate IVF as
yellowish urine which leaves the ordered - to assure that the
output cells without body receives
- afebrile adequate water to accurate amount of
carry on normal fluids and
function. -administer diuretics electrolytes
and anti-emetics as - to regain fluid
prescribe volume balance
 ASSESMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
EXPLANATION
Subjective: Risk for infection The immune Within the 8˚ Independent: Goal met.
“Okay na ako.” related to system is the shift, the client - establish rapport - to facilitate Within the 8˚,
external factors body's defense will remain free cooperation as well the client
Objective: against bacteria, from the signs as to gain pt’s trust remained free
- received pt. lying viruses and other and symptoms of - note risk for -to help in the from signs and
on bed ĉ ongoing foreign organisms infection occurrence of infection immediate symptoms of
IVF of PNSS 1L to or harmful (e.g. compromised prevention infection
run for 12˚ @ chemicals. It is host)
850cc level, very complex and - instruct client/SO in - to educate them in
infusing well to left it has to work techniques to prevent the modes of
- conscious and properly to protect spread of infection transmission of the
coherent us from the - reinforce strict hand infection
-ambulatory harmful bacteria washing - serves a s a first
- ĉ non-productive and other line defense against
cough organisms in the - encourage to infections
- ĉ good skin environment which maintain good health - good health help in
turgor may infect our status by adequate fighting infections
-ĉ good capillary body. If our hydration
refill immune system is - provide regular
- on soft diet compromised it perianal care - to reduce risk of
- ĉ good appetite, can affect the - maintain sterile ascending UTI
consumed all food normal production technique for invasive - to
served of white blood cells procedure prevent infection
- ĉ presence of from the bone
active bowel marrow. And if Dependent:
sounds in the there is an - emphasize necessity - premature
abdomen increase in number of taking antibiotics as discontinuation of
- voiding freely ĉ of WBC it can directed treatment when
yellowish urine therefore cause - administer or client begins to feel
output infection. monitor medication well may result in
- afebrile regimen and note return of infection
client’s response - to determine
effectiveness of
therapy