ASSESSMENT NURSING SCIENTIFIC PLANNING IMPLEMENTATION SCIENTIFIC RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

Subjective: Acute pain Mechanical, Short Term Independent:  Promotes Outcome Achieved.
“Masakit yung tiyan related to thermal or Outcome:  Encourage cooperation Client stated 3 ways
ko lalo na kapag gastrointestinal chemical stimuli. After 3 hours of patient to from the client. of relieving pain such
kumakain” as irritation nursing verbalize (Fundamentals as imagery,
verbalized by the secondary to interventions: about pain. of Nursing by application of hot
client. dengue Nociceptors 1. the client Taylor 5th e. and cold compress
hemorrhagic will state 3  Provide p.1216) and therapeutic
fever.
Afferent Nerves
ways of comfort  This calms and touch.
Objective: relieving measures such soothes the
>Facial grimace pain such as as deep patient.
when palpating the imagery, breathing (Fundamentals
abdominal area. End terminals application exercises like of Nursing by
>Guarding behavior of hot and yoga and Taylor 5th e.
on the abdominal cold meditation. p.1216)
area. unmyelinated C compress  Encourage
>Pain scale of 5 out fibers and and diversional  To divert
of 10. myelinated-A delta therapeutic activities attention from
fibers touch. (TV/radio, pain.
2. the client’s socialization (Fundamentals
pain scale with others, of Nursing by
will decrease imagery) Taylor 5th e.
spinal cord from 5/10 to  Provide p.1216)
3/10. application of
brain cortex hot and cold  To relieve pain
compress. in the muscle
area. Maternal
and Child Health
Pain  Provide Nursing 5th e. by
 therapeutic Pilliteri page
touch. 547)
 To promote
feeling of
REFERENCE: comfort.
Maternal and Child (Maternal and
Health Nursing 5th e. Child Health
by Pilliteri page 545 Nursing 5th e. by
Pilliteri page
547)
 An information
baseline
comparison
from previous
 Monitor Vital data. (Manual of
signs. Nursing
Procedures Vol. I
by Locquiao,
Cruz, Arguelles
and Lontoc page
122)

 To comply with
the physician’s
Collaborative: order. (Manual
 Administer of Nursing
Mefenamic Procedures Vol.
Acid and II Locquiao,
Toradol Manalastas,
(analgesic) as Mejilla and
ordered. Merin. page 3)
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective Data -Hyperthermia related to Short – Term Goal Independent

 Pale and weak disease process as -After 30 mins. of
in appearance evidenced by weak and -After 30 mins. of -v/s taking -To establish a data continuous T.S.B client’s
 Dry mucous pale appearance Nsg. Intervention base. temp. subsides to 37.4 ۫C
membrane client’s temp. will
. subside to 37.5 ۫C ↓ -Tepid sponge bath -To open pores and -After 8 hours of duty
Measurable Data release excess heat pt. has better fluid
V/S Long – Term Goal in the body. volume as evidenced by
T – 38.1 -Remove excess -To promote moist mucous
-After 8 hrs. of duty blankets comfort and membrane.
pt. will maintain prevent convulsion.
fluid volume at
functional level -Increase fluid intake -To prevent further
dehydration

-Measure accurate I/O -To assess fluid

volume
- provide health
teachings to parents -To mobilize
(importance of hand secretions
washing)

-To enhance Health

awareness