DATE: OCTOBER 27, 2023 TIME: 9:30 AM

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Decreased After 8 hours of Independent: After 8 hours of

“mabilis po cardiac output nursing Assess and monitor vital To serve as baseline nursing intervention,
akong related to intervention, the sign data the patient displayed
mapagod”as altered patient will hemodynamic stability
verbalized by contractility display Assess skin color and To monitor worsening as evidenced by:
the secondary to hemodynamic Temperature tissue perfusion (cool, BP: 100/60 mmHg
Patient. rheumatic heart stability with vital clammy, and pale) Temp: 36.5 °C
disease signs within Pulse rate: 115 bpm
Objective: normal limits Respiration: 22 cpm
Low Hgb: 7.6 Instruct on ways to reduce To reduce cardiac
g/dL the strain, promote
BP: 90/60 workload of the heart. recovery, and improve Goal partially met
mmHg Get enough rest overall well-being.
PR: 124 bpm Provide rest periods with
RR: 24 cpm activity
Temp: 36.8 °C Calm and comfortable
-easy Environment
fatigability
-weak in Dependent:
appearance Administer supplemental To maintain a good
oxygen as ordered oxygen
level for the patient

Administer medications as
needed (Ace Inhibitors) To improve heart
function,
decrease patient’s
symptoms and
decrease
cardiac workload
 DATE: OCTOBER 27, 2023 TIME: 9:30 AM
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data: Fatigue related After 3-5 hours of Independent After 5 hours of
“madali po akong to nursing Assess the client's energy To test the patient’s nursing
mapagod” as inadequate intervention, the levels and ability to perform tolerance for proper interventions, the
verbalized by the tissue patient will work. intervention and plan a patient verbalized
Patient. oxygenation as verbalize Activities the patient can daily schedule of activities. understanding on
evidenced by understanding on or cannot perform and it’s how
Objective data: low how to conserve effect physically. to conserve energy
Low RBC: Rbc, Hgb, Hct, energy and and
3.98 10^12/L pale cooperation in Encourage adequate rest To reduce fatigue, promote cooperation in
Low Hgb: complexion personal periods and avoid strenuous activity tolerance and personal
6.9 g/dL and weak management of Activities prevent energy loss management
Low Hct: appearance fatigue of fatigue.
22.1%’ Educate energy conserving To relieve fatigue and
techniques: conserve energy Goal partially met.
Pale complexion Using chair to seat
Weak appearance Avoiding rushing
Scheduling activities

Advice patient to take To increase energy level

balanced nutrition with foods and treat anemia.
high in iron

Dependent:
Monitor laboratory studies To monitor effectiveness of
(Rbc, Hgb, Hct) interventions and patient’s
status.

Administer blood To provide or replace blood

transfusions as ordered or blood components due to
Anemia.
 DATE: OCTOBER 27, 2023 TIME: 9:30 AM
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective data: Imbalanced Imbalanced Weigh patient To monitor weight after 5 hours of
“Mga gulay po na Nutrition: less Nutrition: less routinely loss/gain nursing
dahon dahon, yung than body than body interventions,
nakatanim lang po requirements requirements Observe and record To monitor caloric intake. the patient was able
sa bakuran, isda po related to Failure related to Failure the client’s food to
minsan, hindi po to ingest the to ingest the intake. demonstrate an
mahilig sa karne” proper amount of proper amount of To meet the nutritional understanding on
as verbalized by nutrients as nutrients as Emphasize needs of the patient. the
the evidenced by evidenced by importance of eating importance of
Patient BMI of 14.2 BMI of 14.2 balanced nutrition consuming nutritious
(underweight) (underweight) foods (health Foods.
Objective data: and thin and thin education)
Weight: 32kg appearance appearance Goal partially met
Height: 150 cm Encourage patient to nutritional needs.
BMI: 14.2 have a high calorie For weight gain
(underweight) diet.
Thin (protruding
bony prominence Encourage patient to To stimulate appetite
express
food preferences

Advice patient to Increased motility of the

avoid GI
foods that increase tract may result in
peristalsis and fluids diarrhea
that and impair the absorption
cause diarrhea of needed nutrients.
 DATE: OCTOBER 27, 2023 TIME: 9:30 AM
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

infection After 8 hours of Independent After 8 hours of

associated with nursing Observe proper hand To reduce the nursing interventions,
chronic illness interventions, the washing likelihood of the patient is free of
(Rheumatic heart patient will be when rendering care transmitting any infection and
disease) High WBC free of any to patient pathogens to verbalizes an
14.81 10^9/L infection and Teach the patient the patient. understanding of
verbalizes an and Family proper measures on how to
understanding of hand washing to be prevent infection as
measures to done before caring evidenced by
prevent infection. for the patient agreeing,
nodding and
Check for Needs to be restating.
medications causing monitored for
immunosuppression increased risk for Goal met
infection
Dependent:

Monitor laboratory To monitor for

values; changes or
WBC, RBC alteration.
(hemoglobin)
DATE: OCTOBER 27, 2023 TIME: 9:30 AM
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

noncompliance After 6 hours of Determine the So that they may be After 6 hours of
with prophylactic nursing patient’s/families aware nursing
drug therapy due interventions, the perception of long-term effects interventions,
to financial patient will of her condition and the patient
constraint verbalize an realize the severity of verbalized
(economic status) understanding of the an understanding of
her health status disease (when non- her health status as
and improve her compliant) evidenced by
adherence to agreeing and
medications Direct to community To provide nodding.
resources: information on
Tell them all health care patient assistance Goal partially met.
services offered by the programs
government and where to which can help them
claim comply to the
medications

Discuss the patient’s To better understand

reasoning and feelings their Reason
for non-compliance

Provide clear, thorough, For her to be aware

and understandable
explanations
about why medication
compliance is important
and what would be its
effects to her (therapeutic
communication).
of what
she needs to do for
her health to be
better and to prevent
further
complications to
develop