Assessment Nursing Scientific Goal Intervention Rationale Evaluation

Diagnosis Explanation
Subjective data: Disturbed Sleep is Long Term Goal: Independent: Independent: Long Term
“Paputol-putol ti sleeping important in After rendering of home was NOT MET
pinagturog ko pattern order for us to visits and nursing 1. Assess past patterns 1. Sleep patterns are During our 2nd
provide of sleep in normal
gamin kanayon nak related to interventions: unique to each last home visit
energy for environment: amount,
makariing ti rabii ta physiologica physical and  the patient will be individual. patient verba
bedtime rituals, depth,
mapanak umisbo” l mental able to know on that he still suf
length, positions, aids,
as verbalized by the interruptions activities. how to manage his and interfering agents. sleep disturba
patient. such as Sleep own condition The patient sl
nocturia disturbance is independently to a maximum to
Objective Data: often become self-reliant 5 hours only
associated
 Sleepy and to improve his 2. Instruct to avoid 2. For patients may
with type 2
appearance sleeping states large fluid intake before need to void during
diabetes
 Yawning bedtime. the night.
mellitus. The
relationship
between sleep
and blood
sugar levels 3. Instruct the SO for 3. To promote rest.
goes the other the different
way, too. nonpharmacological
“When blood management (e.g.,
sugar runs back rub, bedtime care,
higher or than pain relief, comfortable
normal, you position, relaxation
will experience techniques).
polydipisia or
urination more
often. In other
words, extra 4. Educate the patient 4. It is important to
blood sugar on several measures mention the needed
goes into the for sleep promotion, precautions and
urine and pulls such as avoiding heavy reminders to better
water from meals, smoking before promote sleep.
 your tissues,
so you pee bedtime, caffeine
more. You containing beverages,
may find that and alcohol. Also,
you’re waking mention proper fluid
up multiple and food intake
times per night
to go to the
bathroom,
which can 5. Encourage the 5. Adhering to a
disrupt sleep. patient to adhere to a consistent sleep and
dedicated and rest schedule helps
consistent sleep and regulate and manage
rest schedule. the cicadian rhythm.

6. The patient’s
6. Suggest a rest or
environment heavily
sleep conducive
influences his rest or
environment
sleep onset. Turn off
the TV and refrain
from using cellphone
to avoid noise for him
to help the patient
sleep better.

Assessment Nursing Scientific Goal Intervention Rationale Evaluation

Diagnosis Explanation
Subjective data: Activity Short Term goal: 1. Monitor vital signs 1. To provide
Elevated
“Nanghihina ako intolerance before and after the accurate Short term goa
blood activity using the same baseline
lalo na kapag related to After 1 hour of nursing was met:
glucose intervention and home arm and a properly information
nasa trabaho, generalized After 1 hour of
visit, the client will be fitting cuff. for
gaya noong ako weakness monitoring nursing
able to verbalize and
ay nagtratrabaho sa and use energy for this Intervention and
Inability of
farm”, as sedentary conservation indicates home visit, the
cells physiological
verbalized by the lifestyle as techniques to enhance client was able
to use the activity tolerance and levels of
client. evidenced verbalize and
insulin participate in desired tolerance.
by uses energy
hormone activities.
Objective Data: verbalization conservation
2. Increase patient 2. Increases
 Weak of participation in ADLs as confidence techniques to
appearance fatigue or tolerated. level/selfesteem and enhance activit
Vital Signs: weakness. Sugar tolerance tolerance and
BP: 120/80 mmHg molecules level. participate in
PR: 67 bpm remain in desired activitie
RR: 20 cpm the 3. Encourage 3. Exercise
bloodstream progressive activity decreases
.
through selfcare and the blood
exercise as tolerated. glucose level
as the
demand for
Inhibits the
glucose in
cell’s cells
capability to increases
absorb and with physical
use activity.

4. Alternate activity with 4. To prevent

periods of excessive
Decrease
rest/uninterrupted sleep fatigue.
energy
or
weakness
5. Discuss with patient 6. To provide

Activity
intolerance
 Assessment Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosis Explanation
Subjective data: Acute pain Hemorrhoids After 1 hour of nursing Independent: Independent: After 1 hou
“Nagsakit ken related to are interventions, the  Assess the  Assessment nursing
marigatan nak inflammation varicosities in patient will verbalized patient’s pain using provide baseline interventions,
the superior or data to plan
tumakki isu of prolapsed the different ways to PQRST goal was met
inferior intervention
umininom ak ti varices hemorrhoidal manage the pain patient able
biofitea” as venous verbalized
verbalized by the plexus.  Educate the  This will increase different ways
patient Internal patient to explore patient’s comfort manage the pa
Objective Data: hemorrhoids and this will
 Guarding result from the for different relieve pressure
Behavior dilation and comfortable and pain
enlargement position such as
 Facial Mask
of the superior side lying position
plexus while
V/S as follows: external
BP: 120/80 mmHg hemorrhoids  Sitz bath helps to
Temp: 35.9 result from the  Advice the patient relieve pain
RR: 25 enlargement to have a sitz bath
HR: 67 and dilation of
the inferior
O2 sat: 96%
plexus.  To divert the
Pain scale: 6/10 Hemorrhoids mind of the client
 Provide diversional
are from pain
therapy like
considered to
watching
be caused by
television, music
increased
and etc
venous
pressure in
the  To prevent
hemorrhoidal painful defecation
plexus.  Advice the patient
to continue taking
laxative as
prescribed

 This is to made
him realize that
 Educate the this is a serious
patient about his health problems
condition, such as and to increase
causes, risk factors self- reliance
and complications