Assessment Planning Intervention Evaluation

Subjective Short Term Goal: Independent Short Term Goal:

" masakit yong sa left waist ko After 8 hours of nursing intervention After 8 hours of nursing
sa likod isa yon sa mga the patient will be able to: -Accurately record intake and output intervention the patient will be able
nararamdaman ko" as - Patient will demonstrate use of (I&O) noting to include “hidden” fluids to:
verbalized by the patient. relaxation skills to relieve pain. such as IV antibiotic additives, liquid - Illustrated the usage of pain-
- Patient will report relief/control medications, frozen treats, ice chips. relieving relaxation
Objective of pain. Religiously measure gastrointestinal techniques as evidence by
losses and estimate insensible losses reporting relief or control of
-decrease consciousness
(sweating), including wound drainage, pain.
-slurred speech Long Term Goal: nasogastric outputs, and diarrhea
After 48 hours of nursing intervention
the patient will be able to: -Insert indwelling catheter, as indicated. Long Term Goal:
After 48 hours of nursing
NURSING DIAGNOSIS - Improve urine output as -Monitor urine specific gravity. intervention the patient will be able
Fluid volume excess related to evidenced of specific to:
compromised regulatory gravity/laboratory - Weigh daily at same time of day, on
mechanism (renal failure) investigations around normal; same scale, with same equipment and - Improved urine output as
stable weight, vital signs within clothing. evidenced of specific
the patient's normal range; and gravity/laboratory
no edema. - Assess skin, face, and dependent areas investigations around
for edema. Evaluate degree of edema normal; stable weight, vital
(on scale of +1–+4). signs within the patient's
normal range; and no edema
- Monitor heart rate (HR), BP, and
JVD/CVP.

- Auscultate lung and heart sounds.

-Scatter desired beverages throughout

the 24-hour period and give various
offering (hot, cold, frozen).
- During peritoneal dialysis, position the
patient carefully: elevate the head of the
bed.

- Watch out for complications such

as peritonitis, atelectasis,
hypokalemia, pneumonia and/or shock.

Dependent

 - Administered 100 mg IM of thiamine

as prescribed by the physician