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Assessment Diagnosis Planning Intervention Rationale Evaluation

Cues: Excess fluid WIthin 8 hours of - Monitor the vital signs - To obtain baseline data After 8 hours of nursing
 Edema volume nursing intervention of the patient and general condition of intervention the patient
 Skin taut, related to the patient the patient. significant other will be able
shiny underlying significant other will to verbalize understanding
health be able to verbalize - Monitor intake and - Provide status information of individual dietary and
condition understanding of output. to establish the fluid monitoring of intake and
individual dietary balance fluid needs output as evidence by:
and monitoring of replacement. “Bantayan na nako iyang
intake and output. kinaon ug iyang gi-ihi o gi-
- Provide or recommend - Obtaining and utilizing libang”
balanced nutrition electrolytes and other
minerals depends on client Goal Met
regularly receiving them
in a readily available form.

- Assess neuromuscular - To evaluate for presence


reflex of electrolyte imbalance

- Review the laboratory - To evaluate degree of fluid


results for abnormal and electrolyte imbalance.
findings.

- Elevate edematous - Reduce tissue pressure and


extremities, change risk skin breakdown.
position frequently

- Place in semi-Fowler’s - To facilitate movement of


position , as diaphragm, thus
appropriate improving respiratory
effort
- Emphasize need for
mobility and/or - To prevent stasis and
frequent position reduce risk of tissue
changes. injury.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Cues: Impaired comfort related Within 8 hours of nursing DEPENDENT Within 8 hours of
Subjective Cues to illness related symptoms intervention the patient’s - Determine the type - A comfort scale nursing intervention the
“Gi-alimootan lang sya significant other will be of discomfort the can help patient patient’s significant
day.” As verbalized by able to engage in behaviors patient is identify focus of other will be able to
significant others or lifestyle changes to experiencing, such discomfort. engage in behaviors or
Objective Cues: increase level of ease. as physical pain or lifestyle changes to
- Drowsy feeling of increase level of ease of
- Weak discomfort. the patient as evidenced
- Restless - Monitor VS - To look by the significant others
- Diaphoretic for significant “ Medyo okay na gamay
- Fanning changes in vital iya pamati day.”
signs Goal Met.
-Discuss - To provide
interventions/activit nonpharmacologica
ies such as l pain management.
therapeutic touch,
massage; play
therapy and humor.
- Provide age- - To promote ease
appropriate comfort and relaxation and
measures to refocus attention.
- Teach client and - To maximize
significant other about opportunities for se
the non-pharmacologic lf-control over pain
ways to lessen the pain. manifestations.
INDEPENDENT
- Encourage - To prevent fatigue.
significant others to
let the patient have
an adequate rest
periods.
- Encourage age- - To alleviate
appropriate patient’s
diversional discomfort.
activities (e.g., play
time, games, and
socialization).

- Instruct significant - To decrease


others to provide physical discomfort
routine position associated with bed
changes. rest ad also ensure
good circulation.
- Advise significant - To boost patient’s
others to let the body resistance to
patient eat fruits infections that may
and vegetables. lead to further
complications.
- Instruct significant - Body needs 3.5 L
others to let the of water daily as
patient have an the body has
adequate fluid sensible and
intake as tolerated. insensible water
losses. More water
intake aids in the
recovery and
prevents
dehydration.