Assessment Nursing Diagnosis Planning and Nursing Evaluation

Goal Intervention /
Rationale

Subjective: Diagnosis: After 4 hours of Nursing Interventions After 4 hours of

nursing – Monitor the vital nursing intervention
“ Nung hinawakan ko Risk for intervention the signs for baseline the client was able
po tiyan ko malambot at Imbalanced client will be able data to verbalize
masakit din po siya “ as Nutrition: Less to verbalize – Calorie intake understanding on
verbalized by the client. than body understanding on should be calculated. why having a
requirements R/T having a To identify balanced diet is
impaired fat balanced diet and nutritional important and the
Objective: digestion due to her pain scale inadequacies and/or client’s pain scale
obstruction of bile will decrease needs, keep remarks decreased from 9/10
- Facial Grimace flow from 9/10 to 4/10 regarding appetite to to 4/10
- Pallor a minimum.
- Pain Scale: 9/10 – Provide a pleasant
environment at
mealtime and remove
irritating stimuli to
enhance hunger and
reduce nausea.
– Examine for
nonverbal symptoms
of discomfort
associated with
decreased digestion,
such as abdominal
distension, frequent
belching, guarding,
and a reluctance to
move.
– Instruct the client
to eat nutritional
foods in order to
have a balance diet.
– Ask the client to
drink plenty of water
in order to urinate.
– Consult with the
client about their
likes and dislikes,
foods that make them
feel bad, and their
desired meal plan to
give the patient a
sense of control and
encourage eating.