BSN 2 Sec 3 Grp B

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: A 37 year old women STO: Dx: STO:

has been admitted
"Hindi ako due to salpingectomy Within 8 hours of  Explore patient’s  Patients who (Goal Met)
makatulog ng (Removal of one effective nursing perception of reason experienced short term
maayos ". interventions, the problems may have Within 8 hours of
(unilateral) or of sleep difficulty and
patient will be able to: insight into the effective nursing
two(bilateral) fallopian probable relief
Objective: etiological factors of the interventions,
tubes. measures to assist
a) Verbalization of problem (e.g., fear the patient will
 Restlessness feeling rested treatment.
caused by results of a improve in
 Presence of Sleep is a basic b) Improvement in sleeping pattern
eyebags sleeping pattern diagnostic test, concern
human need. It is a and show of
 Yawning c) Demonstrate or over a son getting
universal biological being rested
 Weakness show of being divorced, depression
process common to
rested. over the loss of a loved
all human being. It is LTO:
Nursing Diagnosis: one). Knowing the
required for reasons
specific etiological LTO:
Disturbed sleep such as to cope with Within 24-48 hours of
factor will give
pattern related to the every day effective nursing (Goal Met)
appropriate nursing
grief. stresses, to avoid interventions, the
interventions.
patient will: Within 24-48
fatigue, to conserve
hours of
energy, to refurbish a) The patient will effective nursing
the mind and body, report optimal
 High percentage of interventions,
and to enjoy life more balance of  Assess client's sleep patterns sleep disturbances can the patient’s will
fully. The sleep-wake sleep
affect the recovery of fall asleep
is composed of b) Falls asleep without difficulty
the patient.
different complex without difficulty and report an
stages of optimal
consciousness
namely: rapid eye c) Awakens  To determine usual balance of
movement (REM) refreshed and is sleeping pattern and to sleep
sleep, nonrapid eye not fatigued compare if there are
 Observe the sleeping
movement (NREM) during day any improvements on
pattern, bedtime routine,
sleep, and sleeping pattern of the
and the usual number of
wakefulness. Amount patient
hours of sleep and rest.
of time spent during  So that patient will have
the REM sleep an understanding of the
diminishes as person’s importance of care
age increases. Age being don’t to her.
 Explained the necessity of
and personal
disturbances for monitoring
characteristics affects
vital signs
the amount of sleep
that individuals  These can promote rest
require. Generally, Tx: and sleep
the demands for
 Provide nursing aids or
sleep decrease with
teach significant others to
age. Disturbance in provide certain activities to
the patient’s sleep promote sleep. (e.g., back
pattern and rub, bedtime care, pain
wakefulness may be relief, comfortable
temporary or chronic. position, relaxation  This promotes minimal
Sleep pattern may be techniques) interruption in sleep and
disturbed by the rest.
following factors:  Prepare patient for
necessary anticipated  To enhance the ability
bright environment,
interruptions/disruptions. to fall asleep.
frequent monitoring
and treatments,  Encourage to drink warm
traveling, jet lag, milk
sharing a room with
another, use of
medications
Edx:
(especially alcohol,
 This lessens the patients
antihistamines,
chances to void at
antidepressants,  Instruct to minimize night.
beta-blockers, drinking large fluid before
bronchodilators, bedtime.  This will encourage the
caffeine, regulation of the
 Encourage patient to circadian rhythm, and
decongestants,
follow a consistent daily lessens the energy
narcotics, steroids,
schedule for sleeping and required for
hypnotics, and anti-
awakening as possible. familiarization to
anxiety drugs),
changes in routines changes.
such as in, night-shift
 Bedtime rituals help us
rotations that change
get the sleep we need
one’s circadian  Encourage client to
and give us the ability
rhythms, acute illness, develop a bedtime ritual
to function at peak
or emotional that includes quiet
levels
problems such as activities such as reading,
depression or anxiety.
The major goal for
clients with sleep
disturbances is to
maintain or develop
a sleeping pattern
that provides
sufficient energy for
daily activities. Other
goals may relate to
enhancing the
 client’s feeling of well-
being or improving
the quality and
quantity of the
client’s sleep.

ASSESSMENT:
1. Focus on your Nursing Diagnosis (Subjective and Objective cues should ALL be align with your problem)
2. Subjective data (preferably verbalization from the patient and must be in an open and close quotation otherwise if it is coming from the mother
or any significant other, it must be categorize as subjective data from a secondary source or an objective data [if it can be perceived by the
senses, verified by another person observing the same patient, and tested against accepted standards or norms] from a secondary source).
3. Objective data (start with the most obvious observation that is related to your nursing diagnosis to the less obvious, followed by abnormal vital
signs that are related to your problem and any laboratory results that are relevant to your problem)
4. For Nursing Diagnosis, use the 3-Part Statement: PES Format (Problem + Etiology + Signs and Symptoms) Three parts are joined together by
“related to” or “associated with” and “as manifested by” or “as evidenced by”
EXPLANATION OF THE PROBLEM:
1. Should be in paragraph form, it’s just like doing your pathophysiology but explaining in detail how the problem arise in relation to your objective
data and other signs and symptoms manifested by the patient that are related to your problem.
2. DO NOT FORGET to indicate your source as a basis in coming up with your explanation of the problem.
OBJECTIVES:
1. Must follow the concept of SMART (Specific, Measurable, Attainable, Realistic and Time bound).
2. STO (Short Term Goal). In theory it covers your acute care (till 6 months). But for our requirement we measure our STO within the shift (0 – 8 hours).
A better parameter would be using ranges of time depending on the planned activities.
 3. LTO (Long Term Goal). In theory it covers your chronic care (6 months and above). But for our requirement we measure our LTO within the first day
to the third day or one rotation (24 – 72 hours). A better parameter would be using ranges of time depending on the planned activities.
NURSING INTERVENTION:
1. Dx (diagnostics) should be based on your SUBJECTIVE and OBJECTIVE DATA.
2. Tx (therapeutics) should be arrange as ICDS (Independent nursing function, Collaborative [other health-care professional aside from the
physician], Dependent nursing function [physician/doctor], Supportive [Significant others, clergy/priest, and non-health care professional]
3. Edx (educative) should be based on the most needed by the patient that is relevant to the nursing diagnosis. (you can also base it on your STO
and LTO if there are educative goal)
RATIONALE:
1. It must be aligned with your nursing intervention and relevant to the case of you patient.
2. For the administration of medication, your rationale should be the indication of the drug in relation with the patient’s case.
EVALUATION/ EXPECTED OUTCOMES:
1. Evaluation for ACTUAL PROBLEM and your NURSING INTERVENTION should be past tense.
2. EXPECTED OUTCOME for POTENTIAL PROBLEM and your NURSING INTERVENTION should be future tense.
3. Should evaluate (GOAL MET, GOAL NOT MET or GOAL PARTIALLY MET) accurately and should be supported by results from your STO and LTO.
4. For expected outcomes (GOAL MET IF, GOAL NOT MET IF or GOAL PARTIALLY MET IF), and give parameters for the IF.
5. Should discuss or make recommendation/s for goal not met and partially met.

Always remember that NURSING PROCESS is SYSTEMATIC, PATIENT-CENTERED, GOAL-ORIENTED AND DYNAMIC.