Name: M.D.A. Neil Abraham M.

Lalap BSN3-E Group21

Age / Sex: 6yrs old/ male Ms. Maria Theresa Basto RN
Medical Diagnosis: S.V.I. r/o U.T.I. w/symptoms of DHN
Nursing Diagnosis: Readiness for enhanced self health management r/t stability of health status as manifested by expression of desire to manage illness.
Short Term Goal: At the end of my shift, patient and parent will assume responsibility for managing treatment regimen.
Long Term Goal: At the end of the hospitalization , the patient and parent will be advised and continue management of health regimens for the fast
recovery of patient at home..

Date Cues Problem Scientific Rationale Nursing Intervention Rationale Evaluation

08/09
/10 S: Readiness for A pattern to educate and instruct -promote parent involvement in -health teaching of the parent for Goal met:
>“opo, O.K. Na enhanced self the patient and significant other or planning for and implementing further management of recovery after the patient and
pakiramdam ko” health parent in physical, psychospiritual, added tasks and responsibilities d/c in the hospital parent was properly
as verbalized by management. environment or social dimension instructed with
the patient. that can be strengthened for the health teachings ,
maintenance and continual and assumed
O: management of health regimen. -verified patients parent level of -to provide opportunity ensuring responsibility for
> with good knowledge and understanding completeness of knowledge base for further
appetite to therapeutic regimen future learning. management at
> good urine home.
output
> (-) diarrhea
> (-) disuria -identify steps necessary to -to lessen confusion regarding on the
> afebrile reach desired health goal management of health stability of the
patient