Manuel S.

Enverga University Foundation

Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjection: Knowledge After 8 hours  Assess the client  Clients may Goal met: the
“sabi ng doctor deficit related of nursing and family’s have inaccurate mother of the
may TB daw ang to current interventions, knowledge information patient
anak ko sa buto, condition and the patient’s and misconceptio about how verbalized
ano po kayang treatment as mother will ns regarding lifestyle understanding of
ibig sabihin? evidenced by able to peptic ulcer behaviors the disease
” as verbalized frequent verbalize disease, lifestyle contribute to process and
by the mother inquiries understanding behaviors, and peptic ulcer treatment
Objective: of the disease the treatment disease. regimen
 Frequent process and regimen. Explain  An
inquiries treatment the understanding of
about his regimen pathophysiology the disease
condition of disease and process helps to
approximatel how it relates to foster the
y 4-5 times the functioning willingness to
every shift of the body. follow the
 Instruct the client recommended
in what signs and treatment plan
symptoms to and modify
report to the behaviors to
health care prevent
provider. recurrent
 Discuss the episodes or
therapy options related
and the rationales complications.
for using these  Recognizing the
options. signs and
 Discuss the symptoms can
lifestyle changes help ensure the
required to early initiation
prevent further of treatment.
complications or  The correct use
episodes of of antibiotics
peptic ulcer and acid
disease. suppression
medications can
promote rapid
healing of an
ulcer.
 The
modifications of
lifestyle
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

behaviors such
as alcohol use,
coffee, and other
caffeinated
beverages, and
the overuse of
aspirin or other
nonsteroidal
anti-
inflammatory
drugs is
necessary to
prevent
recurrent ulcer
development
and prevent
complications
during the
healing phase.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Risk for After 6 hours of  Ascertain  To determine After nursing

“Ang laki ng imbalanced nursing understanding of informationa intervention the
pinayat niya mula nutrition: less interventions individual l needs of patient was able
nung magkasakit than body client will nutritional needs client. to verbalized
siya“ as verbalized requirement verbalize  Assess weight,  To establish understanding
by the mother related to understanding measure or baseline about causative
inadequate of causative calculate body parameters. factors and
OBJECTIVES: dietary intake as factors and fat and muscle  Indicates necessary
 Weak in manifested by necessary interventions to
mass and other protein-
appearance body weakness interventions to promote optimum
anthropometric energy
 weight loss and loss of promote nutrition
weight optimum measurements. malnutrition.
from 29kg to
nutrition  Observe for  To monitor
approximately
absence of effectiveness
19kg
subcutaneous fat of efforts
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

and muscle and dietary

wasting, hair plans.
loss, fissuring of
nail, delayed
healing of
wounds, gum
bleeding or
swollen
abdomen.
 Weight regular
and graph
results.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Risk for fluid and  After 8  Assess for  This will After doing the
“nagsusuka siya electrolyte hours of the signs of provide necessary nursing
nung dumating imbalanced nursing dehydration a data interventions and
kami dito “ as related to intervention including that teachings, the
verbalized by the inadequate the client skin turgor, could be client:
mother dietary intake exhibit oral mucosa, used to Achieved
As manifested by signs of etc evaluate appropriate urine
OBJECTIVES: poor skin turgor improveme  Monitor I & the output
 Poor skin nt in O and IV proper
Participated in
turgor health teaching
hydration fluids intervent
 Dry mucous Demonstrated use
status  Keep a quiet ion that of relaxation
membrane  Review environment the client skills to reduce
 Sunken eyeball ways to and calm needs. anxiety
 Capillary refill improve the activities  To
at 3 seconds client’s  Provide reduce
 Weight loss hydration health the
from 29kg to status teachings on dryness
approximately Ensure that the avoidance of of the
19kg client is dehydration oral
receiving right mucosa
amount of  To
maintenance determin
fluids e if IV
fluid and
electroly
te
replacem
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

ent are
needed
 To
reduce
stress
and
anxiety
 To
promote
awarenes
s on
related
factors

ASSESSMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATIO

S N
Subjective: Ineffective Short Term INDEPENDENT: After 8 hours of
“nahihirapan po akong airway Goal:  Encourage  Deep nursing
huminga” as clearance deep breathing intervention,
verbalized by the related to After 8 hours breathing promotes Goal Partially
patient inflammation of nursing exercises oxygenation Met.
of the lungs intervention, before The patient was
Objective: as evidenced secretions will controlled able to
 Rapid by chest x- be mobilized, coughing
breathing/ ray airway patency  To improve >demonstrate
tachypnea will be  Assist patient productivity coughing and
 With maintained free in coughing of the cough deep breathing
productive of secretions, exercises  Adequate exercise every
 Diminished as evidenced  Increase fluid fluid intake 1-2 hours
and patient’s ability intake, as enhances during the day
adventitious to effectively appropriate liquefaction
breath sounds cough out of pulmonary >Client’s
(crackles) secretions, secretions respiratory rate
 Dyspnea clear lung and is not within
 V/S taken as sounds, and facilitates normal range
follows: uncompromise expectoration (RR – 27)
R:33 bpm d respiratory s of mucus
 Chest x-ray rate  Monitor rate,  Provides a >Inspiratory
resulte: rhythm, basis for crackles can
consider depth , and evaluating still be heard at
consolidation effort of adequacy of the right lower
pulmonary respirations ventilation lobe
infectious or  To promote
>Cough
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

nature right  Assist patient drainage of continues to be

lung. into moderate secretions productive
high back rest and better
positions lung
expansion
 Auscultate  Decreased
lung fields, airflow
noting areas occurs in
of decreased areas
of absent consolidated
airflow and with fluid.
adventitious Bronchial
breath sounds breath sounds
(normal over
bronchus)
can also
occur in
consolidated
areas.
Crackles,
rhonchi, and
wheezes are
heard on
inspiration
and/or
expiration in
response to
fluid
accumulation
, thick
secretions,
DEPENDENT: and airway
 Administer spasm/obstru
ordered ction
medications  To help
such as loosen and
mucolytic clear the
agents. mucus from
Bronchodilato the airways
rs, (mucolytics);
expectorants decreased
(No resistance in
Medication the
with pending respiratory
biopsy) airway and
increased
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

airflow to the
lungs
(bronchodilat
ors) and to
loosen and
clear mucus
and phlegm
from the
respiratory
tract
(expectorants
)
 A variety of
respiratory
 Administer therapy
nebulizations treatments
as needed may be used
to open
constricted
airways and
liquefy
secretions.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Self-bathing/ GOAL: Independent: > To identify Seen patient
“dati pagkagaling hygiene After 1 day of 1)Determine existing causative/contrib performing self
niya sa labas deficit related nursing intervention, conditions affecting uting factors care activity
diretso na agad to musculo- the patient will ability of individual to >To assess with the help of
siya sa CR para skeletal perform self-care care for own needs, i.e. degree of his mother
maligo,” as impairment activities within level spinal cord injury. disability
verbalized by the as evidenced of own ability with 2)Determine individual >To assess
mother by inability to the help of his strengths of client degree of
OBJECTIVE: wash body or mother 3)Note whether disability
> patient has been body parts, EXPECTED deficient is temporary or >enhances
bedridden ever obtain or get OUTCOME: The permanent, should commitment to
since she was to water patient will: decrease or increase in plan, optimizing
hospitalized source, get in 1)Identify individual time4)Promote client/ outcomes
because of spinal and out of areas of SO participation in > to assist in
cord injury bathroom. weakness/needs problem identification correcting/
2)Demonstrate and decision making. dealing with
techniques/lifestyle 5)Develop plan of care situation
changes to meet self- appropriate to individual >To enhance
care needs situation, scheduling capabilities
3)Identify personal activities to conform to > To enhance
resources that can clients normal schedule. capabilities
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

provide assistance 6)Assist with rehab >To encourage

program client and build
7)Allow sufficient time on successes.
for client to accomplish >Assist patient
tasks to fullest extent of to adhere to plan
ability of care to fullest
8)Assist with necessary extent
adaptation to >To provide
accomplish ADL’s. continuity of
Begin with familiar, care
easily accomplished > To provide
tasks. continuity of
9)Review/modify care
program periodically to
accommodate changes
in abilities
Dependent:
10)Administer
medication regimen
Collaborative:
11)Consult with
dietitian/nutritional
support team

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

“hindi na po siya Impaired After 8hours of Screen for mobility Screening mobility Goal met:
nakakalakad mula physical nursing skills in the following skills helps provide Seen patients
nung nagkasakit siya” mobility related intervention the order: baselines of parent to
as verbalized by the to patient’s parent (1) bed mobility; performance that immobilize the
mother musculoskeleta will immobilize (2) supported and can guide mobility- joint of the
l impairment the joints of the unsupported sitting; enhancement patient
OBJECTIVE: secondary to patient to (3) transition programming and
 Bed ridden pott’s maintain movements such as sit allows nursing
 Inability to sit paraplegia mobility to stand, sitting down, staff to integrate
and stand alone and transfers; and movement and
 Muscle weakness (4) standing and practice
 limited ability to walking activities. opportunities into
perform gross Use a physical activity daily routines and
motor skills tool if available to regular and
 limited ability to evaluate customary care.
perform fine Observe client for Some clients
motor skills cause of impaired choose not to move
 limited range of mobility. Determine because of
motion whether cause is psychological
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

 difficulty turning physical or factors such as an

psychological. inability to cope or
mobility. depression. See
Monitor and record interventions for
client's ability to Ineffective Coping
tolerate activity and or Hopelessness.
use all four Pain limits
extremities; note pulse mobility and is
rate, blood pressure, often exacerbated
dyspnea, and skin by movement
color before and after Techniques such as
activity gait training,
strength training,
Before activity and exercise to
observe for and, if improve balance
possible, treat pain. and coordination
Ensure that client is can be very helpful
not over sedated. for rehabilitating
Consult with physical clients
therapist for further
evaluation, strength
training, gait training,
and development of a
mobility plan.

IV. NURSING PROCESS

A. LONG TERM OBJECTIVES
The study aims to provide adequate nutrition and prevent complications of the client through
collaborative management with physician therapist associate with the nutritionist.

B. PRIORITIZED LIST NURSING PROBLEM

PROBLEM RANKING JUSTIFICATION

Impaired physical mobility
related to musculoskeletal
impairment secondary to pott’s
paraplegia
Ineffective airway clearance
related to the increased
production of respiratory
1 we rank this as the first priority
because this is the main
problem of potts disease and if
its not giving much attention it
can cause to further
complications such as physical
injury
2 Airway must be given the first
attention as based on the rule of
ABC which is Airway,
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

secretions Breathing and Circulation. In

Risk for imbalanced nutrition:
less than body requirement
related to inadequate dietary
intake as manifested by body
weakness and loss of weight
Risk for fluid and electrolyte
imbalanced related to
inadequate dietary intake
As manifested by poor skin
turgor
Self-bathing/ hygiene deficit
related to musculo- skeletal
impairment as evidenced by
inability to wash body or body
parts, obtain or get to water
source, get in and out of
bathroom.
Knowledge deficit related to
current condition and treatment
as evidenced by frequent
inquiries
addition, difficulty of breathing
can cause anxiety to the client
that is why, immediate
attention must be done
3 Although this is under
physiologic needs of a human
we ranked this as the second
priority, it should be the first
thing to be managed because it
can be fatal if left untreated
4 Fluid and electrolytes are
importance in our body, we
rank this as the to be priority
because if it’s not treated the
patients will become
dehydrated
5 Proper hygiene is one way to
prevent the spread of infection
so we chose this as 3rd priority
because it is also the best way
to prevent further complication
6 Knowledge deficit is less
priority among others because
this help the patient understand
about the condition

D. Discharge Plan (M.E.T.H.O.D)

 Medication
 Advised patient to take the prescribed medication continuously at home.
 Always check the expiration date of the medicine before taking.

Name of Drug Dosage & Route Curative Effects Side Effects

Frequency
Ceftazidime 900mg IV Anti-infective; Body as a Whole:
Q8 for 7 days antibiotic Fever, phlebitis,
pain or
inflammation at
injection site,
superinfections.
Acetylcysteine 200mg IV Skin and mucous CNS: Dizziness,
TID membrane agent; drowsiness. GI:
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

mucolytic; Nausea, vomiting,

antidote stomatitis,
hepatotoxicity
(urticaria).
Paracetamol 150mg IV Central nervous Negligible with
PRN Q4 system agent; recommended
nonnarcotic dosage; rash.
analgesic, Acute poisoning:
antipyretic Anorexia, nausea,
vomiting,
dizziness, lethargy,
diaphoresis, chills,
epigastric or
abdominal pain,
diarrhea;
Lactulose 15ml IV Gastrointestinal Flatulence,
BID agent; borborygmi,
hyperosmotic belching,
laxative abdominal cramps,
pain, and
distention
Gabapentin 100mg IV Central nervous : Drowsiness,
BID system agent; fatigue, dizziness,
anticonvulsant tremor, slurred
speech, impaired
concentration,
Vitamin C 7.5ml IV Vitamins Nausea, vomiting,
OD heartburn,
diarrhea, or
abdominal cramps
(high doses).
Albuterol 3cc Neb. Bronchodilator Nervousness,
Q6 Restlessness,
Tremor,
Headache,
Insomnia,
Chest pain,

 Environment/Exercise

Type of Activity allowed/ to be continued:

o Deep Breathing Exercises
o Provide proper ventilation
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

 Therapy/Treatment
o Comply with medications
o Increase Fluid Intake
o Have small meal frequently

 Health Teaching
o Encouraged parents to do proper hygiene for the patient
o Encouraged parents to maintain clean environment
o Instructed the patients family to position the patient in fowlers position while eating to
avoid aspiration

 Out-Patient
o Advise the patient’s family to follow-up checkup as physician’s ordered
o Advise patient and family to consult with physician if signs and symptoms of disease
occur

 Diet

o Eat small meals more often rather than big meals less often. An empty stomach may
makes the symptoms worse.