ACTUAL PROBLEMS

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Disturbed sleeping Short term: Independent: Short term:

pattern related to
"Paputol-putol ang After 3 hours of •Encouraged •L- trytophan is a The goal met, After 3 hours
frequent urination
tulog ko dahil sa rendered patient to drink component of milk of rendered nursing
madalas na pagihi ko nursing milk before going that promotes intervention patient was be
sa gabi.” as intervention to bed. sleep. able to take an adequate
verbalized by the patient will be hours of sleep and reduces
patient. able to identify the frequent urination.
at least one •To reduce the
Objective data:
individual amount of urine n
•Encourage
 Easy fatigability. appropriate the bladder
patient to void
 Sleepy intervention to therefore
before going to Long term:
appearance promote rest. decreasing the
sleep
Goal partially met after 3
 Urinary output 4-6 number of voiding
days of rendered nursing
times/ night at night..
Reduce the intervention the patient

voiding at night increases the duration of

•Advised patient
• To compensate her sleep.
to take a nap.
the lack of sleep.
Long term:

After 3 days of
•Drinking fluids at
rendered nursing •Advise patient to
night increases the
intervention the limit fluid intake
chance to void
patient will have especially during
since the bladder
enough rest and night.
will be full
sleep.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Disturbed body Short term: •Provide health •To help the Short term:
image related to teaching in client
"Nagulat lang ako After 3 hours Goal met, after 3 hours
temporarily terms of understand the
dahil ang laki ng nursing nursing intervention the
physiological different different
pagabago sa aking intervention the patient was be able to
changes during physiological physical
katawan." As patient will be understand the
pregnancy as changes during changes during
verbalized by the able to relationship of
evidence by pregnancy pregnancy.
patient. understand the pregnancy towards
irritability due
relationship of physiological physical
frequently looking
pregnancy •Encouraged the changes. Long term:
Objective data: in the mirror to see
towards pregnant women •To help the Goal met, After a week
changes in hour
Irritability due frequently physiological to share her client to reduce of nursing intervention
body.
looking in the mirror to physical concerns. her irritability. the patient was be able
see changes in the changes.
Changing her to accept the physical
body.
concerns may changes happened
help her relax. during her pregnancy
Long term:
journey
Enlargement of the After a week of
abdomen due the nursing • To help the
pregnancy intervention the •Provided health client
physiological. patient will be teaching in terms understand the
able to accept of different different
the physical physiological physical
changes changes during changes during
happened during pregnancy. pregnancy.
her pregnancy
journey.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Short term: After 4 and a half
SUBJECTIVE Knowledge After 4 and a half Provided health For effective hours of nursing
DATA: deficit related to hours of nursing teachings about breastfeeding intervention the
“ Unang proper position of intervention the breastfeeding patient performed
Assessment
breastfeeding ko ito Diagnosis
breastfeeding. Planning
patient will at least Intervention Rationale Evaluation
the first breast
diko alam paano Acute pain Shortperform
Term: 1 Independent  Provides . feeding position
Proper positioning Soap will remove
related to
yung tamang pag Diagnosis
Assessment 1. Assessed pain,Rationale
breastfeeding Intervention
Planning informationEvaluation
to aid Short thatTerm Goal:
we discuss.
After 6 hours of (Hold baby - tummy the natural oils
breastfeed “.” as urinary tract position. noting location and in determining Evaluation After 6
Subjective data: nursing intervention Independent:
Short term: to tummy, baby's •To gain that are present
Short term:
verbalized by the infection intensity. choice or hours of nursing
the patient’s nose and chin patients on your breasts
should trust
Subjective
"PAkiramdam data:
ko AfterLong
6 hours of •Establish rapport After
patient. term: 2. Encouraged effectiveness of 2 hours of rendered
interventions, the
painscale will be be placed against the and
and cooperation nipples and
“Masakit ang ako After 48 hours
sobrang pagod nursing
Afterintervention
48 hours ofMonitored BP
increase fluid interventions nursing patients pain is of
reduce to at leat 4/10 breast) will contribute to
atpagihi
parangko”hinahabol
OBJECTIVE
as
DATA: the patient
nursingwill Determine
intake To  Increase intervention,
obtain nursing
the patient
tolerable.
verbalized by the Long term: drying and
koTemp
ang hinga
36 ko” as display blood
intervention, Breastfeed
the baseline every
vs. report
3. Monitored 23 hydration flushes
baseline intervention the
displayed hemodynamic
client. cracking,
verbalized by the pressure
After 7 days within
of her Review hours, 8-10
signs of times stability. Longmother
termwas able
BP 160/100 Mother will be ableof bladder fullnessProvides bacteria and Goal:
patient normal range
effective shock daily . to gain After 7
78 Bpm Decrease to: nursing 4. Provided toxins
opportunities to Evaluation
Promote ableLong
To be retention to Term: knowledge about
19 Rpm cardiac output intervention the comfort
How measer
to get good  changes
track Urinary days of Nursing
Objective Data: Long•Term:Express breastfeed The patient theshallproper
have way to
related to patient’s pain will be adequate backrest
rub,by(Make may
likeattachment develop, Intervention,the
Objective data: Afterphysical
3 days ofand To preventproperly demonstrated
and for patient’s
holdactivities
her that
baby,
decrease relieved or controlled decreasing
helping
sure patient
baby sucks the causing tissue pain is
Restlessness psychological
nursing intervention stimuli hypovolimic
assume position the safetyreduce
of the the workload
breastfeed of her
the
-Facial grimace venous return areola, not justofthe distention. relieved.
BP: 160/100 comfortwill
the patient in shock baby. heart.
comfort baby and clean
-Restlessness secondary to nipple. Baby's top Promotes
breastfeeding
sustain normal Dependent: her breasts
eclampsia and bottom lip To relaxation,
maximize
should
-Painscale of 7/10 rangepractice
of blood and Administered
Dependent: • To obscure
be turned out. sleep refocuses
Baby'speriods
techniques
pressure and hypertensive
Administered any distractions
Laboratory: chin should be attention and
demonstrate drugs as ordered
medication as thatenhance
may interfere
Urinalysis pressed into the may
activities that byprescribed
the doctor.y the with the feeding
• State at breast) coping ailities
reduce the
least one resourcemedical • To find an
workload of the practitioner.
for breastfeeding easier and more
heart. Clean breasts only
support.
Promotional Problem
ASSESSME
ASSESSME
NT NT DIAGNOSI
DIAGNOSIS PLANNING
PLANNING INTERVENTIO
INTERVENTION
N RATIONAL
RATIONALE EVALUATIO
EVALUATION
N
Subjective Data: SReadiness for After 8 hours of Independent E To promote After 8 hours of
Subjectivedata:
Ano po bang Readiness
enhanced Short
nursing
term:intervention
After 2 Independent: -To determine
parents Short
nursing
term: The goal was
maadvice niyo for
parenting hours
theof
client
nursing
will be -Established rapport.need/motiva
knowledge ofmet intervention
after 2 hoursthe
of
“Dahil unang
para sababy
pagaalaga
nga enhance intervention,
able to enumerate
the -Established rapport. tion forinfant nursing
goalintervention,
was met the
namin to
sawalapa
aking baby”
akongas parenting as patient
concepts
will beand
able Performed physical improvemen
physical patient
parents
was able
actively
to
masyadong
verbalized
idea sa
by the evidenced by to: clarify roles of assessment with
-Ascertained t. characteristicIdentify
assume
their own
pagaalaga
mother
sa bata kaya expresses parenting and parents and
motivation and show s and strengths,
responsibility
individual
for
ready naman kaming desire to -Identify
expressown typical newborn
confidenceexpectation for a -To foster
behavior needs,
emotional
and methods
and and
matuto” Objective:
as evidenced by enhance strengths, characteristics. Pointimprovemen
in taking care of change.  To promote resources.
physical care and
the patient
 Shows parenting. individual
their newborn
needs, out state traits such t of familiarity well being of
manifestation and methods and as quiet
-Make time awake
for and parenting
withskills. Longnewborn
term: Theandgoal
Objective data: cues to
of eagerness resources to meet listening tofeeding
concerns behaviors wasexpresses
met after 3 days of
Parents expresses readiness
and them. of the parents. -To promote
and decreasenursing
confidence.
intervention, the
desire to enhance
willingness to optimalparental patient was able
parenting Encouraged parent
cooperate - -Involved all wellness.
anxiety and demonstrate improved
participation in care
members of the to enhance parenting behaviors and
Long term: After behaviors such as
family in learning. parental verbalize realistic
3 days of diapering, formula
feeling of information and
nursing feeding and bathing
-Encouraged contribution expectations of parenting
intervention, the
parents to identify as newborns role.
patient will be Encouraged visitation
positive outlets for primary
able to: and access to health
meeting their own caretakers.
services and provides
needs.  To promote
-
continued
Demonstrate
- proper
improved parenting
parenting and
behaviors.
ongoing
learning
 ASSESSME DIAGNOSI PLANNING INTERVENTI ON RATIONAL EVALUATIO
NT S E N
Subjective data:
ASSESSMENT Readine
DIAGNOSIS Short term: AfterINTERVENTION
PLANNING 7 Independent: -To improve EVALUATION
RATIONALE Short term: The
Subjective data: ss for
Readiness hours
Short term: After Independent: patient’s
-To help the Short goal
term:was
Themetgoal
“Tuwing gabi dahil sa
for enhance sleep1 hour of nursing - baby motivations.
to suck was metAfter 7 hours
after 1 hourofof
\ pagihi ko ng madalas of nursing
“Pangunang anak as
enhance intervention, the - Establish ed properly and nursingnursing
intervention,
hindi na ako makatulog related to intervention, the rapport. -The patient interventio n, the
ko ito kaya gusto knowledge patient will be Established prevent the patient understand
ng maayos kaya discom patient will be able willhave a patient was
kong malaman of breastfeedi able to: rapport aspiration. the importance of able
gagawin ko lahat g to:
kung ano an ng fort due to -Assessed the propertobreast
diiscufeeding.
ssed
sasabihin ng doctor strong motivation
tamang pagbreast frequent -Understand patients ascertain how
-Discuss how to -Assessed the and high
para hindi na ako -
feeding” as urination. the importance of mother’s expectation
desiresfors and to
achieve optimal expectations to
mahirapan” as Long term: The goal
verbalized by the proper breast feeding motivati
infant. achieve
sleep. improve herself
verbalized by the was met after 12
patient” feeding. on for optimal
patient to a hours of nursing
-Discuss dietary -Provide improveme
health nt. sleep
Long term: After good intervention, the
Objective data: matters, such asteaching aboutthe .
12 hours of lifestyl patient verbalize
limiting intake of benefits of breast
Objective data: nursing -Assured e. understanding of the
-Mother Expresses chocolate and feeding.
intervention, the patientthat Long
benefits term: The
of breast milk
desire to enhance caffeine or alcoholic
patient will be occasional goal was
and aplied the met
ability to exclusively beverages. -Demonstrate how to
 Easy fatigability. able to: sleeplessne ss After
different 12 hours of
techniques
breastfeed. support and position
 Sleepy appearance should not nursing
of breastfeeding.
theinfant.
Urinary output 4-6 -Verbalize threaten. intervention, the
Long term: After 12
times/ night understandin g of patient was able
hours of nursing -
the benefits of -Encouraged to
intervention, the Encourage dskin-
breast milk. regular exercise Show personal
patient will be able
to- skin contact.
during the day concerns of sleep
to:
-Apply different toaid in stress quality and
breastfeeding
-Express personal control and release quantity.
positions.
concerns of sleep of energy. \
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective data: Readiness for Short term: After Independent:  Indicates Short term: The
enhanced 6 hours of nursing deficient goal was met after
“Ano bang pwede knowledge health interventio n, the  Established knowledge or 4 hours of nursing
kong gawin para patient will be rapport. misinformation intervention, the
maging maayos ang able to verbalize  To develop patient had been
aking kalusugan at understanding of  Assessed clients plan for able to verbalize
hindi na ako atakihin information perceptions of their learning understanding of
ng higblood ko”. as gained current health  To facilitate information gained
verbalized by problems learning
the patient Long term: After process -
 Determine
4 days of nursing  To promote
motivation/
Objective data: interventio n,the wellness Long term:
expectations for
The client manifested patient will be The goal was met
learning
cooperative,follows able to use after 4 days of
instruction, active and information to  Review specific nursing
asking about normal develop dietary changes/ intervention the
condition of his health individual plan to restrictions with client had been
meet health care client able to use
needs. information to
develop individual
plan to meet health
care needs.
pregnancy. such as ruits,
proper nutrition vegetables, fat-
for the diet of free and protein
pregnancy such foods.
as fruits, vegetables,
RISK POTENTIAL
ASSESSM ENT DIAGNO PLANNING IMPLEMENTATIO RATIONALE EVALUATION
SIS N
Subjective Risk for Within 3 hours of ● Establish rapport.  Building up trust GOAL MET.
: unstable rendering nursing helps nurse-patient
After 3 hours of
The patient blood interventions the ● Monitor interaction more
rendering the
stated that pressure patient will be able the patient’s vital effective.
nursing interventions
“hindi ko related to to recognize that signs.  To have a baseline the patient was able
maiwasan unhealthy diet our body is data
 Educated the patient to understand the
kumain ng profoundly affected
on the bodys nutrional  This will allow the importance of
matatabang by the food we
needs patient to gain nutritious food to our
pagkain”. consume.
knowledge in the body and the
 Provided good oral
area of how to patients vital signs
hygiene
Long term: independently care are also stable
Objective:
for oneself upon
BP: 160/100 Within 5 days of Collaborative discharge
rendering nursing
● Discussed MD the  Good oral hygiene
interventions the
can increase an
potential need for
patient will be able
individual’s appetite.
refferal to a
to display a stable
The oral mucosa is
dietitian
blood pressure
also a vital part of
.
reading and
salvia production
increase their intake
which will further aid
of nutritious foods.
in the digestion of
food.
 Utilizing appropriate
resources is a vital
part of being a nurse.
The dietitian will be
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATI RATIONALE EVALUATION
ON
Subjective: Risk For After 4 hours of >Establish rapport >To gain the client trust Goal met client
Naglolotion ako Impaired skin nursing >Monitor VS .>To obtain data were able to
palagi dahil integrity as intervention .>Note age and sex forcomparison. verbalize
parang nagddry evidenced by client will be able >Assess mood, >to evaluatedegree/source individual factors
ang ang balat ko dry skin to verbalize abilities,and of riskinherent in that causes skin
kahit marami understanding of personal styles. theindividual situation impairment
akong uminom ng individual factors >Provide .>to evaluate pt.’sattitude
tubig” as that contribute to healthteachings which maycontribute to
verbalized by the possibility of skin regarding skinbreakdown Goal met the

patient impairment. theimportance of .>To increase the patients patient were able

maintaining an knowledge thus,prevention to demonstrate

Objective: Long Term: intact andmoist skin of skinbreakdown is behaviors to
Dry skin After 3 days of .>Adviced the clien realizedand taken prevent dry skin.
nursing a balance, and intoconsideration
intervention the nutritious food .> To improve
client will be able especiallyfoods rich clientsimmune system
to demonstrate in Iron andvitamin
behaviors to
prevent dry skin.
children in the home. overcome
Determine parenting
challenges in the barriers.
Observe the parent’s
parent’s
attitude toward the infant.
capabilities.
Monitor interactions when
Parent were able
feeding and changing the
to participate in
infant or a reluctance or
classes to