ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute pain related to SHORT TERM : INDEPENDENT

"Sobrang sakit daw yung mastoid pain After 30 min. Of nursing  Provide a patient  To provide comfort SHORT TERM :
kanyang tainga sa kaliwa " interventions patient for a comfortable for the patient After 30 min. Of nursing
as verbalize by the mother will be able to : position like lying interventions patient will be
   Express reduction with operated ear  To reduce swelling able to :
in pain/reduction up and pressure on  Express reduction in
OBJECTIVE:  State degree of  Elevate the head operated ear pain/reduction
 Ear Discomfort pain is tolerable of bed  State degree of pain is
 Facial Grimacing  Appear relaxed  Avoid Heavy  To prevent tolerable
 Moaning and crying and sleep/rest lifting , straining , dislodging the  Appear relaxed and
 Vital Signs Taken appropriately exertion do not tympanic sleep/rest
PR- 120 LONG TERM : blow nose for 2-3 membrane graft appropriately
TEMP-37.1 After 8 hours of nursing weeks after LONG TERM :
RR-20 intervention patient will surgery  Provide relief After 8 hours of nursing
be able to : COLLABORATIVE: dicomfort/pain and intervention patient will be
 Remain free of  Administered facilities rest able to :
discomform or narcotics/analgesi participation in  Remain free of
pain cs as indicated postoperafive discomform or pain
theraphy

 ACUTE EAR PAIN

 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
After 8 hours sof
SUBJECTIVE:  Difficient fluid volume After 8 hours of nursing  Monitor and record  Tachycardia , nursinginterventions,
" Masakit daw po ang related to active fluid intervention the patient the vital signs dypnea, or the patient fluid and
kanyang tiyan at dumi volume loss fluid and blood volume  Measure intake and hypotension may blood volume return to
po siya dumi basa po will return to normal output , Record and indicate fluid normal as evidenced by
yung tae niya " as significant changes volume deficit or stable vital signs
verbalize by the mother include urine and electrolyte
stool imbalance
OBJECTIVE:  Increase water  Low urine output
 Sunken eyeballs intake and high specific
 Administer IV fluid gravity indicates
 Restlessness. hypovoclemia
 To replace fluids
 V/S taken as and blood volume
follows:
T: 38.9
PR : 80
RR: 21
Bp: 100/80
  GASTROENTERITIS
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:  Acute pain related After 8 hours of nursing

"Hindi daw po siya to biological intervention , the patients  Assess pain ,  Provides After 8 hours of nursing
makaihi at masakit daw factors such as pain will be relieved or nothing location information to aid interventions the patient
po" as verbalize by the trauma ,or activity controlled . intensity in determining pain will be relived or
mother of disease process choice or controlled.
 Encourage effectiveness of
OBJECTIVE:: increased fluid intervention
 Facial Grimace intake  Increased
 Restlessness hydration flusshes
 Vital signs taken  Investigate report bacteria and toxin
TEMP. - 37.3 of bladder fullness  Urinary retention
PR- 90 may develop
RR - 20  Observe for causing tissue
BP-100/80 changes mental distention and
status , behavior. potentiate risk for
further infection
 Provide comfort  Promote
measure like back relaxation,
rub refocusses ,and
attention
 URINARY TRACT INFECTION