ASSESSMENT DIAGNOSIS INFERENCE/SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

BACKGROUND INTERVENTIONS
Subjective: Disturbed body image Liver cirrhosis, also known After 8 hours of Support and -Caregivers GOAL MET:
as hepatic cirrhosis, is a encourage sometimes allow
Diyak unay related to biophysical chronic hepatic disease nursing intervention After 8 hours of
patient; provide judgmental feelings to
makagarw-garaw nursing intervention
changes/altered characterized by diffuse the patient will be care with a affect the care of
nakong ta agsakit tuy the patient is able to
destruction and fibrotic positive, patient and need to
mangrugi tuy tiyan ko physical appearance able to verbalize verbalize
regeneration of hepatic cells. friendly make every effort to
aginggana likod ko as evidenced by understanding of attitude. understanding of
As necrotic tissues yields to help patient feel
nakong as verbalized changes and
negative feelings fibrosis, the diseases alters changes and valued as a person.
by the patient acceptance of self in
about body/abilities the liver structure and normal acceptance of self in the present situation
Objective: vasculature,
the present situation and identify feelings
impairs blood and lymph flow, Assist -Patient may present
-Yellowish and methods for
and ultimately causing hepatic and identify feelings patient/SO to unattractive
conjunctiva coping with negative
insufficiency. Causes include and methods for cope with appearance as a result
perception of self.
-Distended stomach malnutrition, inflammation change in of jaundice, ascites,
(bacterial or viral), and coping with negative
appearance; ecchymotic areas.
Initial v/s as follows: poisons (e.g., alcohol, carbon perception of self. Providing support can
suggest clothing
T: 37.1 C / axilla tetrachloride, that does not enhance self-esteem
acetaminophen). Cirrhosis is emphasize and promote patient
BP: 110/70 mmHg the fourth leading cause of altered sense of control.
PR: 88 bpm death in the United States appearance
among people ages 35 to 55 (color of
RR: 21 cpm and represents a serious threat clothes, etc).
to long-term health.

Encourage -Family members

family/SO to may feel guilty about
verbalize patients condition
feelings, visit and may be fearful of
freely and
impending death.
 participate in They need
care. nonjudgmental
emotional support
and free access to
patient. Participation
in care helps them
feel useful and
promotes trust
between staff, patient,
and SO.

-Patient is very
Discuss sensitive to body
situation and changes and may also
encourage experience feelings of
verbalization of guilt when cause is
fears and related to alcohol or
concerns. other drug use.
Explain
relationship
between nature
of disease and
symptoms
 ASSESSMENT DIAGNOSIS INFERENCE/SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
BACKGROUND INTERVENTIONS
Subjective: Ineffective Breathing Liver cirrhosis, also known After 8 hours of Auscultate -May indicate GOAL MET:
as hepatic cirrhosis, is a breath sounds, developing
Nu dadduma nakong, Pattern related to nursing intervention After 8 hours of
chronic hepatic disease noting crackles, complications.
jak unay makaanges nursing intervention
intra-abdominal fluid characterized by diffuse the patient will be wheezes, Presence of
as verbalized by the the patient is able to
collection (ascites) as destruction and fibrotic able to maintain rhonchi. adventitious breath
patient maintain effective
regeneration of hepatic cells. sounds may reflect
evidenced by effective breathing breathing pattern
Objective: As necrotic tissues yields to accumulation of
alterations in depth of fibrosis, the diseases alters pattern fluids or secretions.
-Dyspnea the liver structure and normal Absent or diminished
breathing
-Feeling breathless vasculature, sounds suggests
impairs blood and lymph flow, atelectasis.
Initial v/s as follows: and ultimately causing hepatic
T: 37.1 C / axilla insufficiency. Causes include
malnutrition, inflammation
BP: 110/70 mmHg (bacterial or viral), and
PR: 88 bpm poisons (e.g., alcohol, carbon
tetrachloride, -Changes in
Investigate
RR: 21 cpm acetaminophen). Cirrhosis is mentation may reflect
changes in
the fourth leading cause of hypoxemia and
level of
death in the United States respiratory failure,
consciousness.
among people ages 35 to 55 which often
and represents a serious threat accompany hepatic
to long-term health. coma.

-Facilitates breathing
Keep head of
by reducing pressure
 bed elevated. on the diaphragm, and
Position on minimizes risk
sides. of aspiration of
secretions.

Encourage
frequent -Aids in lung
repositioning expansion and
and deep- mobilizing secretions.
breathing
exercises and
coughing
exercises.
 ASSESSMENT DIAGNOSIS INFERENCE/SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
BACKGROUND INTERVENTIONS
Subjective: Acute Pain related to Liver cirrhosis, also known After 8 hours of Assess pain -Assessment of pain GOAL MET:
psychological as hepatic cirrhosis, is a nursing intervention characteristics experience is the first
Nasakit tuy yanti discomforts as such as quality, After 8 hours of
chronic hepatic disease the patients feeling step in planning pain
tiyan ko nakong, evidenced by objective severity, nursing intervention
characterized by diffuse of pain will decrease management
umabot pay inggana cues location, onset, the patients feeling of
destruction and fibrotic and patient will be strategies
jay likod ko as duration and pain decreased and
regeneration of hepatic cells. able to display
verbalized by the precipitating or patient will is able to
As necrotic tissues yields to improvement in relieving factors
patient display improvement
fibrosis, the diseases alters mood, coping
in mood and coping
Objective: the liver structure and normal
vasculature,
-Pain scale of 6; 10 impairs blood and lymph flow, Assess for -Some people deny
being the highest and ultimately causing hepatic signs and the existence of pain.
-Weakness insufficiency. Causes include symptoms Attention to
malnutrition, inflammation relating to pain associated signs may
Initial v/s as follows: (bacterial or viral), and help the nurse in
T: 37.1 C / axilla poisons (e.g., alcohol, carbon evaluating pain
tetrachloride,
BP: 110/70 mmHg acetaminophen). Cirrhosis is
PR: 88 bpm the fourth leading cause of .
death in the United States
RR: 21 cpm among people ages 35 to 55
and represents a serious threat -Some patients may
to long-term health. be satisfied when pain
Assess the
patents is no longer massive;
anticipation for others will demand
pain relief complete elimination
of pain. This
influences the
 perceptions of the
effectiveness of the
treatment of the
treatment modality
and their eagerness to
engage in further
treatments

-Often a combination
of therapies (e.g.,
Assess the mild analgesics with
patients distraction or heat)
willingness or may be more
ability to effective. Some
explore a range patients will feel
of techniques uncomfortable
aimed at exploring alternative
controlling methods of pain
pain. relief. However,
patients need to be
acquainted that there
are other approaches
to manage pain.
 ASSESSMENT DIAGNOSIS INFERENCE/SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
BACKGROUND INTERVENTIONS
Subjective: Activity Intolerance Acute bronchitis often occurs After 8 hours of Assess the - Mention parameter GOAL MET:
related to the after a cold or the flu, as the nursing intervention, client's response helps in assessing After 8 hours of
Haan nak unay result of bacterial infection, the patient will show nursing intervention,
imbalance between to the activity, response to stress
makagaraw-garaw or from constant irritation of an improvement in the patient showed an
supply and oxygen activity tolerance attention pulse physiology and
unay ta maulaw-ulaw the bronchi by polluted air or improvement in
demands as evidenced rate more than 20 activity when there is
nak ngamin nakong chemical fumesin the activity tolerance
by general weakness times per minute an indicator of excess
as verbalized by the environment. It is
in work-related activity
patient characterized by a slight
the frequency of levels
fever that may last for a few
Objective: days to weeks, and is often breaks;
accompanied by a cough that significant
-weakness
may persist for several increase in BP
-dizziness weeks. Acute bronchitis, during / after
symptoms usually resolve activity,
Initial v/s as follows: within 7 to 10 days, however, dyspnea, chest
T: 36.9 C / axilla a dry, hacking cough can pain; excessive
linger for several weeks. fatigue and
BP: 140/100 mmHg weakness;
PR: 98 bpm diaphoresis; dizzi
ness or fainting.
RR: 21 cpm
Instruct patients
about energy - Energy
saving techniques saving technique
, eg, using the reduces energy
bath seat, sitting reduction also helps
as combing hair balance between
or brushing teeth, supply and oxygen
doing activities demand.
slowly.
 Encourage
- Progress activity
activity / self-
increased gradually to
care gradually if
prevent sudden
tolerated. Provide
cardiac work, provide
assistance as
only limited
needed.
assistance needs will
encourage
independence in their
daily activities.
 ASSESSMENT DIAGNOSIS INFERENCE/SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
BACKGROUND INTERVENTIONS
Subjective: Ineffective airway Acute bronchitis often occurs After 8 hours of nursing Assess -Useful in evaluating the GOAL MET
clearance related to after a cold or the flu, as the interventions the patient respiratory rate, degree or respiratory
Haan nak unay After 8 hours of nursing
excessive, thickened result of bacterial infection, will demonstrate depth. Note use of distress and chronicity
makagaraw-garaw interventions the patient
mucous secretions as or from constant irritation of improved ventilation and accessory muscles, of the disease process
unay ta maulaw-ulaw demonstrated improved
evidenced by difficulty of the bronchi by polluted air or adequate oxygen and pursed lip breathing,
nak ngamin nakong ventilation and adequate
breathing chemical fumesin the will show no signs of Inability to speak.
as verbalized by the oxygen and showed no
environment. It is respiratory distress
patient signs of respiratory
characterized by a slight
distress
Objective: fever that may last for a few Elevate head of the
days to weeks, and is often bed, assist patient -Oxygen delivery may be
-fatigue accompanied by a cough that assume position to improved by upright
-DOB may persist for several ease work of position and breathing
weeks. Acute bronchitis, breathing. exercises to decrease
-weakness symptoms usually resolve airway collapse, dyspnea
Encourage deep
Initial v/s as follows: within 7 to 10 days, however, slow or pursed lip and work of breathing
a dry, hacking cough can breathing as
T: 36.9 C / axilla linger for several weeks. individually toler
BP: 140/100 mmHg ated or indicated

PR: 98 bpm
RR: 21 cpm
Evaluate level of
activity tolerance. -During severe or acute
Provide calm and respiratory distress,
quiet environment patient maybe totally
unable to perform basic
selfcare activities because
of hypoxemia and
 dyspnea

Evaluate sleep -Multiple external stimuli

patterns, note report and presence of dyspnea
of difficulties may prevent relaxation
and whether patient and inhibit sleep
feels well rested

ASSESSMENT DIAGNOSIS INFERENCE/SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

 BACKGROUND INTERVENTIONS
Subjective: Deficient Knowledge Obesity is a complex disorder After 8 hours of Determine -Necessary to know GOAL MET:
related to lack level of what additional
Madlaw ko nakong involving an excess nursing intervention
of/misinterpretation of nutritional information to
ket kinanayon nga After 8 hours of
information as accumulation of body fat at the patient will be knowledge and provide. When
nangato presyon ko
evidenced by least 20% over average able to verbalize what patient patients views are nursing intervention
ken maulaw-ulaw nak
statements of lack believes is most listened to, trust is the patient is able to
nu dadduma as desired weight for age, sex, understanding of need
of/request for urgent need. enhanced.
verbalized by the verbalize
information about and height or a body mass for lifestyle changes
patient understanding of need
obesity and nutritional index of greater than 27.8 for to maintain/control
Objective: requirements Monitor v/s for lifestyle changes
men and greater than 27.3 for weight
-overweight women. Obesity isnt just a -To obtain baseline to maintain/control
data weight
-limited movements cosmetic concern. It increases
Initial v/s as follows: your risk of diseases and Identify other
health problems such as heart sources of -Using different
T: 36.9 C / axilla
information avenues of accessing
disease, diabetes and
BP: 140/100 mmHg like books, information furthers
high blood pressure. tapes, patients learning.
PR: 98 bpm Involvement with
community
RR: 21 cpm classes, groups. others who are also
It is different from being
losing weight can
overweight, which means provide support.
weighing too much. The
weight may come
from muscle, bone, fat,
and/or body water. Both
Encourage -Provides opportunity
terms mean that a persons
involvement in for pleasure and
 weight is greater than whats social activities relaxation without
that are not temptation.
considered healthy for his or centered Activities and
her height. around food exercise may also use
(bike ride or calories to help
nature hike, maintain desired
Obesity occurs over time attending weight.
when you eat more calories musical event,
than you use. The balance group sporting
activities).
between calories-in and
calories-out differs for each
person. Factors that might
affect your weight include
your genetic makeup,
overeating, eating high-fat
foods, and not being
physically active.

Patients name: QUILANA, CLARITA

76, FEMALE, WIDOW

DATE/TIME:
10-9-2017
7-3 FOCUS DATA ACTION RESPONSE
Altered Body Comfort
8:00 AM D:Reports of dizziness and weakness; facial grimace noted;
A: initial v/s taken T: 36.3/Axilla; BP:130/90 mmHg; PR: 85 bpm; RR: 20; Bedsi
 de care rendered; Health teachings imparted as follows: have enough rest and sleep; practice proper positioning when lying down
to avoid discomforts; eat a balanced diet
2:00 PM R: Comfortable lying in bed; reported dizziness was relieved