S/O (Data) A P I E

(Focus) (ACTION) (RESPONSE)

Nursing Background Long Term Short Term Intervention Rationale Evaluation
Diagnosis Knowledge
SUBJECTIVE > Tepid sponge bath = hygiene purposes.
Ineffective Innefective airway To facilitate the Patient will performed Comfortability Goal partially met,
“sumasakit dibdib ko airway clearance clearance is the maintenance of promote an patient can manage
pag umuubo ako” as related to excess inability to clear a supply of optimal > Encouraged adequate = Oral fluid the pain but the
verbalized by the tevacious secretions or oxygen to all spontaneous liquid intake replacement is cough is still
patient secretions. obstructions from body cells. breathing indicated for mild fluid uncontrolable.
the respiratory pattern that deficit and is a cost-
tract to maintain a maximize effective method for
OBJECTIVE clear airway. oxygen and replacement treatment.
> espressions of pain carbon dioxide > Changed linen
in chest when exchanged in = important for
coughing the lungs. preventing the
> shortness of breath transmission of germs
PR: 111 RR: 23 > Taught how to cough
effectively = Health teaching for
patient
> Inform patient and
family about relaxation = to produce the
technique to improve body's natural
breathing pattern relaxation response

> Instructed to take = To prevent fatigue

adequate rest

> Watch out for signs = To prevent zero

and symptoms of medication errors
respiratory distress

> Instructed patient to = To prevent sickness

adhere dietary regimen
 S/O (Data) A P I E
(Focus) (ACTION) (RESPONSE)
Nursing Background Long Term Short Term Intervention Rationale Evaluation
Diagnosis Knowledge

SUBJECTIVE
Sleep Sleep deprivation To facilitate the After 8 hours > changed linen = Important for Goal not met
“hindi ako makatulog” as deprivation is most maintenance of of intervention, preventing the patient still cannot
verbalized by the patient related to commonly regulatory patient will transmission of sleep.
health defined as a state mechanisms and identify and use germs
condition in which an functions. measures that > performed tepid
OBJECTIVE individual will increase sponge bath = Hygiene purposes,
experiences rest or sleep on comfortability
> weak looking prolonged time > encouraged patient
> not in the mood periods of time to take naps during = to meet sleep
without sleep. the day requirements

> maintened comfort

in environment and
hygiene = for comfortability
and hygiene
purposes
> taught patient the
use of non = to produce the
pharmacological body's natural
techniques relaxation response
(relaxation)
 S/O (Data) A P I E
(Focus) (ACTION) (RESPONSE)
Nursing Background Long Term Short Term Intervention Rationale Evaluation
Diagnosis Knowledge

SUBJECTIVE Hypothermia In response the To facilitate the After 8 hours >Assessed and >To know the >Goal met; latest
related to hypothalamus maintenance of of nursing monitored vital baseline data. patient’s
Subjective: release of raises the body’s regulatory intervention the signs of the patient. temperature is 37.0
>‘Mainit po ako’ as patient pyrogenic temperature mechanisms and patient will °C sleep.
verbalized. substances that above the normal functions decrease from >Encouraged patient >To promote
triggers the range, The above 38.5 °C to 35.5 to increase body wellness of the
OBJECTIVE hypothalamus normal . °C fluid intake. patient.
temperature are
Objectives: thought to help
>Skin are warm to touch. defend against >monitored body >To assess the
>Body temperature is microbial temperature effectiveness of the
>Vital signs invasion because intrvention
T : °C they stimulate
RR : 24 cpm the motion,
PR : 110 bpm ability and
BP : 120/80 mmHg multiplication of
white blood cells
and increase the
production of
antibodies.