ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Data: “Increased Bilirubin Short Term Independent 1. Gain a good patient- After 8 hours shift,
“Naninilaw ang mata Volume related to Planning: 1. Establish trust and nurse relationship. goal is partially met.
ko at katawan.” Jaundice as rapport. 2. Establish baseline Patient are able to
manifested by After 8 hours shift, 2. Assess the vital data observations. bring back his normal
generalized the nurse will be able signs and compare 3. 3. Identify strength and reduce
weakness and to manage it with the normal deficiencies, suspect the amount of
yellowish extremities symptoms and pattern. the possibility of Bilirubin but his skin
and sclera” provide supportive 3. Assess nutritional intervention and sclera are still
care for the patient history, including 4. To give patient yellow discoloration.
Objective Data: that can further preferred food and comfort.
 Generalized prevent liver damage lifestyle.
weakness and promote liver 4. Provide patient
 With visible health. opportunity to rest
yellowish and calm and safe
extremities environment.
and sclera For the long term goal
after days of therapy
VS Taken as Long Term patient are able to
follows 4pm: Planning: bring back his full
T: 36.8°C After days of nursing Dependent strength, gained back
PR: 63 intervention, the 5. Based on the result his normal skin and
RR: 14 patient successfully or urinalysis, cbc sclera color and most
BP: 120/60 able to prevent the and the result of importantly prevent
8pm: progression of the Bilirubin Testing. the possible infection
T: 36.4°C Hepatitis B due to 6. Administer and progression of
PR: 73 increased bilirubin medication Hepatitis B.
RR: 21 volume. prescribed by the
BP: 120/60 physician.
Patient Name: Ranel Mendenuela
Dx: Jaundice t/c Viral Hepatits B
SN: Idea, Pamela A.
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: “Risk for Imbalanced Short Term Planning: Independent 1. Gain a good After 8 hours shift, goal
“Mahina ako kumain Nutrition Less than 1. Establish trust patient-nurse is partially met. Patient
ngayon at minsan Body Requirements After 8 hours shift, the and rapport. relationship. are able know the
nasusuka” related to inadequate patient will be able to 2. Assess the vital 2. Establish importance of an
nutritional intake, demonstrate behaviors signs and baseline data adequate nutritional
nausea and vomiting” and lifestyle changes compare it with observations. intake and
to regain appetite. the normal 3. Identify demonstrate behaviors
pattern. deficiencies, and lifestyle to bring
3. Assess suspect the back his appetite.
Objective Data: nutritional possibility of
 Generalized history, intervention.
weakness including 4. To give patient
 Weight loss preferred food. comfort.
Long Term Planning: 4. Provide patient
After days of nursing opportunity to
intervention, the rest and calm
patient successfully and safe After days of therapy,
able to maintain environment. goal is fully met.
adequate nutritional Patient are able to
intake and maintain his maintain adequate
VS Taken as follows usual weight. Dependent nutritional status and
4pm: 5. Give 5. To gain regained his usual
T: 36.8°C medications as nursing-patient weight as evidenced
PR: 63 ordered by intervention by increased in weight.
RR: 14 physician. with rapport to
BP: 120/60 6. Cooperate with care givers and
8pm: the family to to give hope for
T: 36.4°C serve foods better status of
PR: 73 that are liked health.
RR: 21 by the patient 6. To facilitate
BP: 120/60 at the same balanced food.
time rich in
nutrients.
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: “Acute pain related to Short Term Planning: Independent 1. Gain a good After 8 hours shift, goal
“Nakakaramdam ako Dysfunctional 1. Establish trust patient-nurse is partially met. Patient
minsan ng pananakit Gastrointestinal After 8 hours shift, the and rapport. relationship. has decreased pain
ng tyan” Motility as evidenced patient will be relieved 2. Assess the 2. Identify the sensation, able to
by facial grimace and and will also be able to clients’ pain onset, intensity, control pain via
guarding behavior” manifest a decrease in scale and duration and diversionary activities
the pain scale. perception. quality of pain. and will have rest and
3. Monitor vital 3. Obtain baseline comfort.
signs and pain data and
scale. changes during
Objective Data: Long Term Planning: 4. Teach patient in onset of pain,
 Guarding After days of nursing diversionary for future
behavior on intervention, the activities in comparison
upper right patient is successfully easing pain. after
abdomen free from pain and 5. Promote rest. interventions.
 Facial Grimace prevent any of the 4. To promote
 Pain scale 5/10 underlying conditions relaxation and For the long term goal,
that may lead serious pain reduction. after days of therapy
complications, patient are able to
including the possibility experience relief from
of structural damage to pain, successfully free
the digestive system Dependent from any discomfort
from infection. 6. Administer and prevent serious
VS Taken as follows medication as complications caused
4pm: prescribed by by abdominal pain.
T: 36.8°C the physician.
PR: 63
RR: 14
BP: 120/60
8pm:
T: 36.4°C
PR: 73
RR: 21
BP: 120/60