ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Subjective: You may notice wavelike STO: Dx: STO:

“ ilang araw ng contractions (peristalsis)  Assessed skin turgor and oral  to correct dehydration
nagsusuka ang anak that ripple across your Within 3 hours of nursing mucous membranes for signs of immediately (Goal Met)
ko”as verbalized by the intervention the patient will dehydration.
baby's upper abdomen soon
mother. be able to: After 3 hours of
after feeding but before a) moistened mucous  Monitored fluid status in  Verifying if the patient is on nursing
Objective: vomiting. This is caused by membranes relation to dietary intake a fluid restraint is necessary. intervention the
 dry mucous stomach muscles trying to b) Stop vomiting patient was able to
membranes/ force food through the  This will allow objective data moistened mucous
dehydration narrowed pylorus and can LTO:  Assessed intake and output. in determining the patient’s membranes and
 Sunken cause dehydration. net loss of fluid. free from vomiting.
fontanelle Within 24 hours of nursing
 Weight loss SOURCE/S: intervention the patient will LTO:
 Vomiting be able to: Tx:  Oral fluid replacement is
 Poor skin turgor https:// a) have a normal skin  Encouraged the patient to drink indicated for mild fluid (Goal Met)
turgor prescribed amount of fluid. deficit and is a cost-effective
middlesexhealth.org/
Nursing Diagnosis: b) Free from dehydration method for replacement After 24 hours of
learning-center/diseases- treatment. nursing
and-conditions/pyloric- intervention the
DEFICIENT FLUID
stenosis  Provided comfortable  Drop situations where patient patient were able to
VOLUME related to
environment by covering patient can experience overheating have a normal skin
frequent vomiting with light sheets. to prevent further fluid loss. turgor and free
from dehydration.
 Severely dehydrated patients
 Administered intravenous or patients unable to take oral
hydration as ordered. hydration may require IV
hydration to maintain
appropriate hydration level.

 Enough knowledge aids the

Edx: patient to take part in his or
 Educated the patient and mother her plan of care.
about possible cause and effect
of fluid losses or decreased fluid
 intake.
 To keep the baby healthy
 Encouraged to breastfeed
instead of using bottled milk.
 It will help allow the patient
 Educate patient and family on and family to have a better
possible causes of dehydration. understanding of the
diagnosis and preventative
measures they can take in the
future to avoid dehydration.

ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Subjective: Insufficient knowledge and STO: Dx: STO:

ineffective health
“Ayoko munang management are related Within 1 hour of nursing  Assessed for factors that result  To assess the causative or (Goal Met)
kumain, wala pa akong intervention the patient will in alterations in health. contributing factor.
to a lack of access to
gana” as verbalized by be able to: After 1 hour of
the patient information, a lack of time, nursing
 Monitored vital signs.  To provides baseline data.
and anxiety in gaining a) understand the intervention the
Objective: weight consequences of having patient was able to
ineffective health  To discuss to her the benefits verbalize
 Ascertained client’s
 Loss in SOURCE/S: management. of treatment. understanding of
understanding of the condition
Appetite and treatment. the consequences
 Weakness http://www.scielo.org.co/  To assist client to problem of having
  Report of scielo.php? LTO:  Identified individual perceptions solved solutions. ineffective health
unhealthy script=sci_arttext&pid=S16 and expectations of treatment management.
eating habits 57-59972022000302236 Within 24 hours of nursing regimens.
 Food hesitation intervention the patient will LTO:
be able to: Tx:
Nursing Diagnosis: (Goal Met)
a) gain appetite.  Provided positive  To encourage continuation
INEFFECTIVE reinforcements for efforts. of After 24 hours of
HEALTH b) free from weakness. desired behaviors. nursing
MANAGEMNET intervention the
related to lack of c) displays proper eating  Administered vitamins as  To help her gain appetite and patient was able to
knowledge about the habits. prescribed by doctors.
consequences. immunity.. gain appetite, free
from weakness,
 Assisted client to develop  Promotes early recognition of displays proper
strategies for monitoring changes, allowing proactive eating habits and
therapeutic regimen. response. practices good
health
 To improve appetite. management.
 Provided foods that the client
prefers but serve only the
allowed and healthy ones that
can boost her appetite.

Edx:
 To assess client to problem
 Accepted client’s evaluation of
solve solutions.
own strengths and limitations
while working together to
improve abilities.
 To encourage continuation of
 Emphasized importance of client desired behaviors.
knowledge and understanding of
the situation for treatment as
 well as consequences of actions.

 Encouraged client and family  It enhances commitment to

participation in planning and plan, optimizing outcomes.
evaluating process.
 To assist client to problem
 Emphasized use of therapeutic solving solutions.
communication skills.

ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Subjective: “ Ineffective Tissue STO: Dx: STO:

Pakiramdam ko lagi perfusion define as a
akong pagod at decrease in oxygen Within 2 hours of nursing  Assessed skin color,  helps in determining (Goal Met)
nanghihina” as resulting in failure to intervention the patient will temperature, moisture, and location and type of
verbalized by the patient nourish tissues at the be able to: whether changes are perfusion problem and After 2 hours of
capillary level. Resulting a) free from widespread or localized. for changes that might nursing
Objective: for a person to feel fatigue. restlessness indicate circulation intervention the
* restlessness b) free from poor problem. patient was able to
* Moodiness SOURCE/S: concentration free from
* Decrease in peripheral c) increase peripheral  Assessed capillary refill.  to determine adequacy restlessness, poor
pulse https://nurseslabs.com/ pulse. of systematic concentration and
* poor concentration ineffective-tissue- circulation increase peripheral
LTO: pulse.
perfusion/
Nursing Diagnosis:  To evaluate distribution
Within 4 hours of nursing  Determined pulse equality, and quality of blood LTO:
RISK FOR intervention the patient will as well as intensity. flow and success or
INEFFECTIVE be able to: failure of therapy. (Goal met)
TISSUE PERFUSION
a) free from fatigue  Pulse oximetry is a Within 4 hours of
as evidenced by fatigue
b) increased tissue  Used pulse oximetry to useful tool to detect nursing
monitor oxygen saturation changes in oxygenation. intervention the
perfusion and pulse rate. patient was able to
Tx: free from fatigue
 Constant activity can
 Provided rest periods further make the patient and increased tissue
between care activities and feel restless. perfusion.
 prevent long duration of
procedures.
 Exercise prevents
 Promoted active/passive venous stasis and
ROM exercises. further circulatory
compromise.

 Administered medications  These medications

as prescribed to treat facilitate perfusion for
underlying problem. Note most causes of
the response. impairment.

Edx:

 Instructed patient to maintain

bed rest. Schedule activities
to provide undisturbed rest  Activities can increase
periods restlessness and fatigue.

 Provided information about

the prescribed medications.  To increase knowledge
and awareness of the
safe administration,
dosage and side effects.

 Encouraged deep breathing  For effective tissue

exercises. perfusion.