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NURSING NURSING

ASSESSMENT PLANNING RATIONALE EVALUATON


DIAGNOSIS INTERVENTION
S: “Nanghihina Risk for Self- The patient - Monitor and To identify any otherGoal Met. The
ako, hindi ko Care Deficit, will be able record vital signs deviations from patient was able to
magawa yung bathing/hygiene, to take a rest normal. have rest and
mga gusto related to and perform - Determine To assess degree of perform some bed
kong gawin” as weakness as some bed patient strength risk of self-care deficit
exercise during the
verbalized by manifested by exercise and weaknesses 8-hour shift with
the patient. the verbalization after 8 hours continued nursing
and weak and of continued - Provide Adequate rest provides intervention
O: Weak and pale appearance nursing adequate rest enough energy to the
pale in of the patient intervention. periods as well as patient
appearance. comfort & safety
- V/S: measures
T:38.7°C Promotes blood
, P:72 , - Turn the patient circulation
RR: from side to side
24 ,
BP: - Encourage the Promotes blood
90/60 patient to do circulation and ease for
mmHg. some bed patient when in
Presence of exercise recovery
Body Odor
Not well - Provide health To provide clarification
groomed teachings to the and Reinforcement
patient