(1)ASSESSMENT NURSING SCIENTIFIC BASIS GOAL NURSING RATIONALE EVALUATION

DIAGNOSSIS INTERVENTION
In span of 1 hour Independent After 1hour of
SUBJECTIVE: Ineffective airway The physiologic of nursing 1. Frequently assess 1. Early nursing interventions
“mag lisod kog clearance related changes in lung intervention respiratory rate, identification of The client manifested
ginhawa” as to bronchospasm, ventilation that occur The client will be pattern, and breath ineffective decreasing
verbalized by the decreased lung during an acute able to establish sounds. Note respirations allows respiratory rate,
patient expansion asthma attack impair an effective manifestations of timely initiation of RR=22breaths/minute
secondary to both lung expansion respiratory ineffective breathing. interventions. and appeared less
asthma. and emptying. Anxiety pattern so as to strained and
caused by hypoxia and provide adequate 2.Monitored vital 2. Tachypnea, distressed upon
dyspnea compounds ventilation as signs tachycardia, an breathing. However,
OBJECTIVE: the problem by manifested by elevated blood wheezes can still be
T: 36.7 C. increasing the stabilizing pressure, and auscultated from all
PR: 85 bpm respiratory rate. respiratory increasing lung fields and there
RR: 37 cpm rate,decreasing hypoxemia and is still usage of
BP: 150/90 mmhg REF: chest tightness, hypercapnia are accessory muscles
slight to no nasal signs of and nasal flaring
With rapid and  Brunner & flaring and compromised
shallow Suddarth’s decreasing usage respiratory status.
respirations Medical - of accessory
Surgical muscles. 3. Assisted with self- 3. This conserves
Breath sound: Nursing 13th care activities. energy and
Wheezing Edition. reduces fatigue.
 Virtual Medical
Uses accessory Centre (2002– 4. Provided rest 4. Scheduled rest
muscles to aid in 2018) periods between is important to
breathing scheduled activities prevent fatigue
and treatments and reduce oxygen
Exhibits nasal demands.
flaring
5. Placed in High 5. These positions
Fowler’s position reduce the work
of breathing and
increases lung
 expansion,
especially the
basilar areas.

6. instructed and 6. Pursed- lip

assisted to use breathing helps
techniques to control keep airways open
breathing pattern: by maintaining
a. Pursed-lip positive pressure,
breathing and abdominal

Dependent
7. Administered 7. to opens up the
Salbutamol 1 neb c/o medium and large
pulmo as ordered. airways in the
lungs.
Collaboration
8. Monitored with 8. Necessary
laboratory/diagnostic for management
studies as indicated. of underlying and
possible
complications
(2)ASSESSMENT NURSING SCIENTIFIC BASIS GOAL NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSSIS
Independent
SUBJECTIVE: Acute pain Uterine fibroids are After 1 hr of 1. Acknowledge reports of 1. An immediate After 1 hour of
“sakit akong tyan related to benign smooth muscle nursing pain immediately. response to reports of nursing
sa righ side dapit’ intrauterine tumors of the uterus. interactions the pain may decrease intervention the
as verbalized by tissue The exact cause is patient able to anxiety in the patient. client verbalizes
the patient. damage unclear. However, relieve from minimize pain
PS: 8/10 secondary fibroids run in families pain 2. Monitor Vital sign 2. Alterations from from 8 to 3 pain
to Uterine and appear to be partly normal maybe signs of scale (partially
Myoma. determined by -Patient will infection. goal met)
OBJECTIVE: hormone levels. manifest signs
VS follows: Symptoms depend on of comfort 3. Provide rest periods to 3. A peaceful and quiet -The client
T: 36.7 C. the location and size of promote relief, sleep, and environment may demonstrates
PR: 85 bpm the fibroid. Important -Patient will relaxation. facilitate rest. signs of comfort
RR: 20 cpm symptoms include verbalize (goal met)
BP: 140/90 abnormal uterine understanding 4. Encourage diversional 4. To distract attention
mmhg bleeding, heavy or of cause of activities and relaxation and reduce tension -Patient able to
 PAIN: painful periods, pain. techniques such as verbalize
8/10 abdominal discomfort focused breathing and understanding
 Guarding or bloating, painful imaging cause of pain.
behaviour defecation, back ache, (goal met)
 Grimace urinary frequency or 5. Encourage and assist client 5. Deep breathing
face retention, and in some to do deep breathing exercises contribute to
 Slightly cases, infertility. exercises relief of pain
irritable
Dependent
REF: 6.administered hyoscine 6.To alleviate patient
butylbromide as ordered by pain.
 National Center the physician.
for
Biotechnology Collaboration
Information, U.S. 7. Assist with 7. Necessary
National Library laboratory/diagnostic studies for management
of Medicine
 Brunner & as indicated. (e.g., of underlying and
Suddarth’s abdominalX-ray) possible complications
Medical -
Surgical Nursing
13th Edition.
(3)ASSESSMENT NURSING SCIENTIFIC BASIS GOAL NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSSIS
Diabetes mellitus After 2 to 3 hrs Independent After 2 to 3 hrs
SUBJECTIVE: Fatigue Is a group of metabolic of nursing 1.established rapport. 1.To build trust of nursing
No verbal cues related to diseases characterized intervention intervention
decrease by increased levels of patient will be 2.Monitored VS. 2. baseline data patient was able
muscular glucose in the blood able to identify to identify
strength resulting from defects measures to 3. Assessed skin turgor and 3. to monitor for signs of measures to
secondary in insulin secretion, conserve and mucous membrane for sign dehydration conserve and
to Diabetes insulin action, or both. increase body of dehydration. increase body
OBJECTIVE: Mellitus
In type 2 diabetes, energy. energy.
VS follows: Type 1.
people have decreased 4. encouraged patient to 4. to replace fluid loss
T: 36.7 C.
sensitivity to insulin and increase oral fluid intake, and prevent dehydration The patient was
PR: 85 bpm
impaired beta cell free or relieve
RR: 20 cpm
functioning resulting in from signs of
BP: 140/90
decreased insulin Dependent 5. to replace fluid and fatigue.
mmhg
production. Glucose 5. Administered IVF as order electrolytes loss
derived from food by physician.
Slightly irritable
cannot be stored in the 6. to
(+) Dry lips
liver thereby remaining 6. Administered Insulin as improve glycemic control
(+) Pale
into the bloodstream. ordered by physician.
Lab results: The beta cells of the
Erythrocytes islets of Langerhans
(4.39) release glucagon which
Lymphocytes stimulates the liver to
(0.33) release the stored
CBG (352 mg/dl) glucose. After 8 ± 12
hours, the liverforms
glucose from the
breakdown of
noncarboghydrate
substances, including
amino acids resulting to
muscle wasting which
results
REF:

 Scrib
 Brunner &
Suddarth’s
Medical -
Surgical Nursing
13th Edition.
(4)ASSESSMENT NURSING SCIENTIFIC BASIS GOAL NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSSI
S
Independent After 1hr of
SUBJECTIVE: Risk for Uterine polyps are After 1hr of 1. Establish rapport 1. to earn patient trust nursing
“Kusog ang agas blood formed by the nursing and cooperation intervention
sa akon dugo volume overgrowth of intervention patient the
2. Assess patient condition 2.to monitor other signs client was able
basta dalaw na deficit endometrial tissue. patient will have and symptoms
nako” related to They are attached to understanding to verbalizes
heavy the endometrium by a about the understanding
3. Monitor vital signs 3. to obtain baseline
menstruatio thin stalk or a broad present illness. data for pt. of present
illness (goal
n secondary base and extend
4. Weight patient daily 4, change in weight met)
to Uterine inward into the uterus. Patient will have
can provide information
OBJECTIVE: Myoma. The polyps may be no signs of pale The client
need for adequacy for
T: 36.7 C. round or oval, and skin and dry lips blood volume shows normal
PR: 85 bpm range in size from a few replacement skin color and
RR: 20 cpm millimeters (the size of Patient will able moist lips(goal
BP: 140/90 mmhg a sesame seed) to a to verbalize 5. Promote rest and planned 5. plan care to met)
(+) Dry lips few centimeters or importance of activities alternate period of rest
and activity without
(+) Pale larger. There may be proper blood Patient able to
tiring the client
one or several polyps volume on the verbalize
Lab results: present. Uterine polyps body 6. Encourage patient to eat 6. Green leafy importance of
Erythrocytes are usually benign green leafy vegetables vegetables facilitates blood volume in
(4.39) (noncancerous), but cell production the body (goal
Lymphocytes they may cause met)
(0.33) problems with Dependent
7. for the replacement
menstruation (periods) 7. Administered Intravenous of fluid.
or fertility. fluid PNSS 1L @ 100ml/hr

REF:
Collaboration
 clevelandclinic.o 8. Assist with 8. Necessary
rg laboratory/diagnostic studies for management
 Medical Surgical as indicated. of underlying and
Nursing, vol.2, possible complications
9th edition,
Brunner and
Suddarths
 (5)ASSESSMENT NURSING SCIENTIFIC BASIS GOAL NURSING RATIONALE EVALUATION
DIAGNOSSIS INTERVENTION
SUBJECTIVE: Risk for infection Lymphocytes occur in In span of 1hour of Independent After 1 hour of
No verbal cues related to two forms: B cells, nursing 1.Assess the skin for 1.Proper skin nursing
inadequate which produce interventions color, texture, assessment and interventions the
secondary defense antibodies, and T The patient will be elasticity, and documentation patient shall be
as evidence by cells, which recognize free signs of any moisture. facilitates free of any signs of
decreased foreign substances infection prevention of the infections( goal
OBJECTIVE: lymphocytes and process them for breakdown of skin met )
T: 36.7 C. removal The patient will be breakdown which is
PR: 85 bpm able to the body’s first line Patient able to
RR: 20 cpm REF: demonstrate ability of defense againts demonstrate of
BP: 140/90 mmhg to perform pathogens. performing
(+) Dry lips  Encyclopaedia hygienic measures personal hygiene
(+) Pale Britannica 2 Routinely monitor 2.These laboratory (goal met)
Laboratory:  Brunner & The patient will be the patient’s white values are closely
Lymphocytes Suddarth’s able to verbalize blood cell count linked to the The patient able to
(0.33) Medical - which symptoms of patient’s nutritional verbalize the signs
Erythrocytes (4.39) Surgical infection to watch status and immune and symptoms of
Nursing 13th out for function. any infection. (goal
Edition met)
3. Encourage 3. It can reduce
adequate rest stress and boost
the immune
system.

4. Encourage patient 4. A balanced

to eat a balanced intake of omega 3
diet. and omega 6 fatty
acids, protein,
vitamins A, C and E,
zinc and iron is
essential in
reducing risk of
infection.
5. Limit the number 5. This is to limit
of visitors allowed. the risk of the
patient being
exposed to
pathogens.

Collaboration
6. Assist with 6. Necessary
laboratory/diagnostic for management
studies as indicated. of underlying and
possible
complications