Problem #2

Cues/data Nursing
Diagnose
Planning Intervention Rationale Evaluation
Subjective
data:

Client stated
that
nahihirapan
po akong
makatulog kasi
nasakit ung
inoperahan sa
akin

kalimitan po e

Objective data:

-Positive
lethargic

-Positive pallor

-Pain in
perineal area

- 6 measured
in pain scale


Sleep
deprivation
related to
prolonged
discomfort as
manifested by
pain in
perineal area
After effective
nursing
intervention
the client will
increased her
hours of sleep

Objectives:
After 30 to 1
day of
effective
nursing
intervention
the client will:

-Gain
knowledge
about the
importance of
adequate bed
rest and its
benefits

-increase
sleeping hours


Understand
the
importance of
adequate
bedrest


> Established
rapport

> Perform Vital
signs

>Observed and
performed
physical
assessment

>Health
teaching
rendered on:
-Importance of
complete bed
rest and its
benefits

-Ways and
methods to
better sleeping
habits and
increase
comfort

-Advise client to
drink milk


>Provides
baseline data
of the client








>to help to
understand
the
importance of
complete
bedrest









> helps to
promote
relaxation


After 30 to 1
hour of
effective
nursing
intervention
the client was
able to:

-Verbalized the
importance of
complete
bedrest



-do the ways
to better
sleeping habits















Goal was
Partially Met

Problem #1
Cues/Data Nursing
Diagnosis
Planning Intervention Rationale

Evaluation
Subjective
Data:

pili lang ang
kinakain kong
gulay. isda at
karne malimit
kong kainin

wala akong
ganang kumain
dahil siguro sa
operation na
ginawa sakin


Objective Data:


-Pale skin


-skinny
appearance


-Clients food
intake are
lower in
vegetables
Imbalance
nutrition less
than body
requirements
related to lack
of interest in
food as
manifested by
clients food
intake
Goals:
After effective
nursing
intervention
the client will
increased his
food intake in
vegetables


Objectives:
After 30 to 1
hour of
effective
nursing
intervention
the client will:

>Gain
knowledge
about the
importance of
eating
different kinds
vegetables by
answering 3
out of 3
questions

>Increase
vegetable
intake

>Understand
the
importance of
eating
different kinds
of vegetables
and its benefits
By answering 2
out of 3
questions


>established
rapport


> Performed
vital signs


> Observed
and Performed
physical
assessment

>Health
teaching
regarding in:

-Importance of
eating
vegetables and
its nutrients
content

-Advise clients
to take
vitamins


-Avoid eating
junkfoods




>to gather
baseline data
of the client










> To help to
understand the
importance of
vegetables and
its nutrients in
body




> To help her
boost her
nutrients in
her body

>Junk foods
have empty
calories that
provides no
nutritional
help to the
client
caffeinated
beverages
decreased
appetit

After the
intervention
the GOAL WAS
MET