ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Subjective: Imbalanced nutrition related After 1 hour of Nursing Weight client daily After 1 hour of nursing
"My daughter have loss of to weakness and vomiting as interventions the client will intervention the client a
appetite and vomiting after evidenced by loss of appetite be able to verbalized the Stay with client during meals verbalized the importan
meal" As verbalized by the understanding of eating right1. eating right and display
mother and no signs of weakness 2. Suggest eat light, bland sign of weakness or fai
will be present foods (such as saltine
crackers or plain bread)
Objective: After a week of nursing avoid fried, greasy, or sweet After a week of nursing
- unable to speak properly intervention the client will foods intervention the client a
- lethargic be able to gain weight and gain weight and exhibi
- failing 3. Discourage beverages such a sign of imbalance nutri
exhibit no sign of imbalance
- Malnourished soft drinks
nutrition
Vital signs as follow:
BP- 80/60
PR – 85
RR – 32
Temp. - 36.5 C
02 - 93%
 ASSESSMENT
Subjective:
“ My bleeding began on the
tenth day after delivery and
has increased in severity
each subsequent day” as
verbalized by the patient.
Objective:
- Paleness
- Lethargic
- Iron deficient anemia
due to menorrhagia.
- Afebrile
Vital signs as follow:
- BP: 130/90 mmhg
- PR: 85 bpm
- RR: 24 cpm
- O2saturation of 97%.
DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
Abnormal blood clotting After 8 hours of nursing Monitor vital signs every 2 After 9 hours of nursin
throughout the body's blood interventions the patient will hours interventions the patien
vessels related to perform adequate blood perform adequate blood
hemorrhage perfusion and perform stable Monitor the amount of perfusion and also perf
vital signs bleeding through weighing stable vital signs.
blood pads
systemic bleeding
Provide comfort to the client
tendency by like proper breathing
impairing exercise
thromboxane-
Administer medications as
dependent platelet indicated (e.g.
aggregation related Anticoagulants, Oxytocin
abnormal blood (Pitocin) 
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