CONCORDIA COLLEGE, INC.

Higher Education Department

2nd Semester S.Y. 2021-2022

Name: Julius Roi M. Atencio Instructor: Ms. Emmy Macaraeg

BSN-I

Anxiety
Assessment Nursing Goals and Outcomes Interventions Evaluation
Diagnosis
Subjective data: Severe After 8 hours of Independent: Fully met:
Patient reports Anxiety as nursing intervention, Maintaining a calm After 8 hours
excessive manifested the patient will be ableapproach and behavior of intervention,
sweating, muscle by increased to: when working with the the patient was
tensions and autonomic patient, while establishing a able to:
frequent trembling nervous Attained a good rest. good relationship and Wake up on a
when tense or system Maintained a good range healthy environment. well 8 hours of
nervous especially activities, of vital signs. sleep.
during his night diaphoresis, Become more Stay at the
shifts as a call muscle comfortable to his Ensure a quiet, clean, low average range of
center agent, and tensions, attentive nurse. stimuli environment. his vital signs.
also, cannot inadequate Communicate
concentrate well sleep, and After a month of Discuss with the patient: less tensive to
and highly irritability nursing intervention, The occurrence of anxiety the nurse.
irritative to his and the patient will be able attacks and when it After a month
surroundings, unnecessary to: dissipates, and their coping of nursing
restlessness, and movements. Experience reduced mechanisms while being intervention,
with bad habitual anxiety and anxiety empathetic, giving positive the patient was
eating. Related to attacks. comments, and able to:
patient’s Develop a more positive acknowledging his position Demonstrate the
Objective data: cultural view of situations and in a non-forcing approach triggering
Poor concentration background on oneself. and questions. events of the
but highly inside Recognize, anxiety and the
responsive to his workplace. acknowledge, and Remain at patients’ coping
surroundings, and communicate/describe company when levels of mechanism he
had a high pulse his feelings more anxiety are high. has developed
rate. fluently. over time.
Eye bags, swollen Demonstrate coping Observe and monitor Attained a more
eyes, and mechanisms, develop changes on vital signs and positive view to
overweight body problem-solving actions. himself, and
index. capabilities, and show reduced his total
Unnecessary enhanced characteristics Encourage the client to weigh into
movements, slight into facing and participate in relaxation average.
to moderate withstanding pressure events, meditations, and
trembling, and and stress. exercise sessions.
tense muscle Collaborative:
results to Instruct the patient of
continuous appropriate use of anti
sweating of the anxiety and medications as
patient, and doctor’s order of usage.
restlessness.
Client’s meals as aligned
with the dietary plan
recommended by the doctor.

Autonomic Dysreflexia
Assessment Nursing Goals and Intervention Evaluation
Diagnosis outcomes
Subjective data: Risk for After a week of Independent: Partially met
A patient having an SCI seizure nursing Observe sings and After a week of
due to vehicular related to intervention, the symptoms such; nursing intervention,
accident elaborates his loss muscle patient will be monitor vital signs, the patient was able
experiences which control able to: sweating, headaches, to:
includes: Getting secondary Recognize and other signs. Get familiar with the
extreme headaches, to signs/symptoms of situation, perform
frequent increase in Autonomic the syndrome. Elimination of effective measures
blood pressure, feeling Dysreflexia causative stimulus; correctly.
flushed and heavy Identify correct, tight clothings.
sweating, and loss in efficient, and After a month of
muscular control. Also, preventive Discuss with patient nursing intervention,
getting numb on the measures. the signs and signals the patient was able
area below the spinal and how to avoid latter to:
injury. After a month of episodes of seizures. Discuss his experiences,
nursing and turn some
Objective data: intervention, the preventive measures to
Physical assessment patient will be Elevate bed in the become habitual actions
and health history able to: lowest position, and for prevention and
shows that the patient Experience less paddings and railings staying on a healthy
has an SCI, the patient episodes of on the surroundings range.
do not have much Dysreflexia and for support.
control in his muscles seizures. Acquire little to non
results. Perform medical injuries from seizure.
Prevent injuries actions to patient when
CT scan and X-ray during sudden episodes of seizures. Experience seizures at
results suggested an sessions. low levels and very
Collaborative: often to none.
injury on C-1 to C-3 Administer
segment; Tetraplegia. medications as
indicated by the
doctor.

Constipation
Assessment Nursing Goals and Intervention Evaluation
diagnosis outcomes
Subjective data: Constipatio After 3 days of Independent: Fully met
The patient feel pain n due to nursing Investigate delays After 3 days of nursing
within her abdomen inadequate intervention, the on patient’s bowel intervention, the patient
part, and did vomit. fluid intake, patient will be movements. was able to:
infrequent able to: Eliminate the abdominal
Objective data: defecation. Identify Discuss importance pain.
The patient holds her preventive and of chewing well,
abdomen showing that treatment well diet meals, Understand and perform
she’s in pain, and measures to her adequate fluid the preventive and
vomited. situation. intakes, and treatment measures given
emphasize proper by the attentive nurse.
Colorectal transit Describe a relief irrigations as
studies shows slow from discomfort intended. Defecate a normal stool,
movement of stool on and pain. and have an average bowel
the colon due to hard Collaborative: movement.
stools. Established Discuss and inform
schedules for a the client the use of
good diet, equipments as
exercise, and guided by a
bowel movement physician and other
pattern. HCP.

Diarrhea
Assessment Nursing Goals and outcomes Intervention Evaluation
Diagnosis
Subjective data: Diarrhea After 2 days of Independent: Fully met
The patient experience related to nursing Observe stool After 2 days of
abdominal pain, disagreeable intervention, the frequency and nursing
Frequency of liquid dietary patient will be able characteristics. intervention, the
stools with urgency. intake, to: patient was able
increased in Understand the Perform oral fluid to:
Objective data: secretion. underlying cause of intake to patient.
Abdominal pain—7 out his diarrhea, Provide soluble fiber Feel comfortable,
of 10 from pain scale, eliminate the as natural bulking defecate normal
culture stool present abdominal pain, and agents on the diet, to stool, maintain a
liquid stools. maintains a normal slow things down in good skin.
frequency of bowel the digestive tract.
movement and Frequency of
secretion. Discuss with patient defecation dropped
the importance of from frequent to
Consume at least 1, avoiding stimulants. average per
500-2, 000 mL of day/week.
clear fluids, to Collaborative:
replenish weight, and Elaborate diet meals
maintain good skin and discuss the use of
turgor. medication as doctors
indicated.

Fatigue
Assessment Nursing Goals and Intervention Evaluation
diagnosis outcomes
Subjective data: Fatigue due After a month of Independent: Fully met:
The patient reports to lack of nursing Assist patient into After a month of
overwhelming lack of sleep and intervention, the setting priorities and nursing intervention,
energy, decreased in unhealthy patient will be boundaries, restricting the patient was able
performance and pattern, able to: environmental stimuli to:
always tired at inadequate Have a good rest that could affect other Discuss with the
minimal movements, levels of with a healthy plans and schedules. attentive nurse new
lack of interest in exercise, sleeping schedule. habits, his experiences
eating due to emotional Provide dietary meals socially within support
disinterest in stress. Identify individual while encouraging to groups, and describe
surroundings, and actions that consume. events that contribute
being so much in his contributes to being and may contribute to
mind. fatigue. Identify; with patient, the fatigue feeling.
energy conservation
Objective data: Report increased in methods that would Verbalize an increased
Further assessment sense of energy. help in replenishing in energy and
with patient elaborates energy and interest in concentration.
the following: Divide his day into working.
difficulty in sleeping, doing every chore Make a schedule of
imbalance nutritional in his life. Aiding the patient his life chores, with
intake, emotional habits for an effective healthy eating, rest,
stress, physical Eat more nutritious sleeping patterns. and working habit.
tiredness. dietary meals on
healthy schedules. Encourage the patient to
discover new habits,
Understand the could be diversional
needs of exercise activities.
and self isolation as Collaborative:
needed. Recommend
participation on fitness
and workout programs
from support groups.