ASSESSMENT NURSING

PLAN INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Excess fluid After 7 hours of Determine or Note : A severely The goal was not met
Subjective : volume related to nursing estimate the malnourished client can as evidenced by
accumulation of intervention will amount of fluid experience significant decreased urine
“Nung dinala namin fluids in the body have a balanced intake from all fluid shifts and electrolyte output above the
siya dito as evidenced by intake and output. sources : oral, IV, imbalances after normal range.
namamanas sya, edema enteral or nutritional support is
tapos hanggang parenteral feedings, initiated.
ngayon ganun pa Outcome criteria : ventilator and so
din, sa mukha konte -Stabilize fluid forth.
tas sa paa din.” As volume as
verbalized by the evidenced by
mother balanced input and Instruct patient, Information and
ouput (I&O), vital caregiver, and knowledge about
signs within client’s family members condition are vital to
Objective : normal limits, regarding fluid patients who will be co-
 (+) facial stable weight, and restrictions, as managing fluids.
edema free of signs of appropriate.
 (+) pedal edema.
edema
-Verbalize Record I&O So that adjustments can
understanding of accurately; be made in the following
individual dietary calculate 24-hr fluid 24-hr intake if needed
Input : 400ml / 7 and fluid balance noting plus
hours restrictions or minus
Output : 150ml / 7
hours
Elevate edematous Elevation increases
extremities, and venous return to the heart
handle with care. and, in turn, decreases
edema. Edematous skin
is more susceptible to
injury.
 ASSESSMENT NURSING
PLAN INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
After 7 hours of Assess of presence The client may have a The goal was met ,
Risk for infection of host-specific disease that directly
Subjective : related to nursing factors that affect impacts the immune as evidenced by
alteration in skin interventions, immunity : system or may be normal vital signs
“May sugat siya sa may integrity presence of weakened by
kamay tapos may nana patient will remain underlying disease. prolonged disease and absence of signs
pa.” as verbalized by the free of infection. conditions (e.g. and symptoms of
mother diabetes, kidney
infection.
disease, heart failure)
Outcome criteria :
or their treatments.
Objective :
-Identify Assess and monitor Patients with poor
 Pus from a wound interventions to nutritional status, nutritional status may
 Pain scale : 7/10 weight, history of be anergic or unable to
 Weak prevent or reduce weight loss, and muster a cellular
 Restlessnes risk of infection. serum albumin. immune response to
pathogens making
them susceptible to
-Demonstrate infection.
techniques, lifestyle
changes to promote Monitor vital signs For baseline data

safe environment. Encourage intake Helps support the

of protein-rich and immune system
calorie-rich foods. responsiveness.

Teach the patient Patients and SO can

and/or SO to wash spread infection from
hands often, one part of the body to
especially after another –
toileting, before handwashing reduces
meals, and before these risks.
and after
administering self-
care.

Wear gloves when To reduce bacterial

appropriate to colonization
minimize
contamination of
hands, and discard
after each client,
Instruct the
client/significant
other to wash
hands, as
indicated.
Recommend
routine body
shower or scrubs,
when indicated.
 ASSESSMENT NURSING
PLAN INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Fatigue related to At the end of the Assess vital signs. To evaluate fluid status The goal was met as
Subjective :
sleep deprivation 7 hours shift, the and cardiopulmonary evidenced by
as evidenced by client will improve response to activity increased energy
“Matamlay sya tapos lethargy, sense of energy level.
gusto lagi lang tiredness and Establish realistic Enhances the
drowsiness activity goals with the commitment to promoting
nakaupo or nakahiga client and encourage optimal outcomes
kase di sya forward movement.
makatulog ng ayos Plan interventions to To maximize participation
dito sa hospital.” As allow individually
verbalized by the adequate rest
periods. Shedule
mother activities for periods
when the client has
Objective : the most energy.

Avoid or limit To avoid negative impact

 Lethargic exposure to on energy level
 Tiredness temperature and
humidity extremes
 Drowsiness
Assist the client to Promotes a sense of
identify appropriate control and improves self-
coping behaviors. esteem