ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SMay NGT ako tapos naka

connect pa ditto yung
isang fecal drainage ang
hirap sa pakiramdam as
verbalized by the client.

O> Alert, conscious,
coherent

>Afebrile

>Oriented to time, place
and person

>Dry &poor skin turgor

>Capillary refill after 2-3
seconds

>Muscle strength of 5/5
on both upper and lower
extremities.

>weight loss (160 lbs-120
lbs within 6 months)

>NGT-Fecal drainage,
blood streaked stool (10-
20ml)

>Auscultated 5-6
borborygmic sound in
each quadrant for 1
minute.Tympany heard @
each quadrant

>V/S taken as follows: BP:
130/80,HR:78,RR:20,T:36


Impaired bowel
incontinence r/t
incomplete emptying
of bowel
SHORT-TERM:

After 8 hours of
nursing intervention,
the client will be able
to verbalize
understanding of
causative

LONG-TERM:

After 3 days of
nursing intervention,
the client will be able
to identify
individually
appropriate
interventions
INDEPENDENT:

>Established rapport and
Assessed general
condition

>Assessed historical
aspects of incontinence
with precipitating events

>Auscultated & palpated
abdomen





>Noted stool
characteristics (color,
odor, consistency,
amount,
shape, and frequency)

DEPENDENT:

>Administered
medications(enemas,
laxatives,etc.) as
prescribed by the doctor

COLLABORATIVE:

>Reviewed results of
diagnostic studies and
laboratory


>To gain trust and baseline
data


>To identify the most
common factors in
incontinence

>To determined for
presence, location, and
characteristics
of bowel sounds & any
distention, masses,
tenderness

>Provides comparative
baseline.






>To relief client for any
discomfort




> To identify for
abnormality in the values.

SHORT-TERM:

After 8 hours of
nursing intervention,
the client was able to
verbalized
understanding of
causative

LONG-TERM:

After 3 days of
nursing intervention,
the client was able to
identified individually
appropriate
interventions
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
SMalaki na rin ang
binagsak ng timbang ko
kumpara dati kase di nako
nakakakain ng maayos
dahil na rin sa kundisyon
ko as verbalized by the
client.

O> Alert, conscious,
coherent

>Afebrile

>Oriented to time, place
and person

>Dry &poor skin turgor

>Capillary refill after 2-3
seconds

>Muscle strength of 5/5
on both upper and lower
extremities.

>weight loss (160 lbs-120
lbs within 6 months)

>NGT-Fecal drainage,
blood streaked stool (10-
20ml)

>Auscultated 5-6
borborygmic sound in
each quadrant for 1
minute.Tympany heard @
each quadrant

>V/S taken as follows: BP:
130/80,HR:78,RR:20,T:36
Disturbed body image
r/t illness
SHORT-TERM:

After 8 hours of
nursing intervention,
the client will be able
to verbalize
understanding of
body changes


LONG-TERM:

After 3 days of
nursing intervention,
the client will be able
to recognize and
incorporate body
image change into
self-concept in
accurate manner
without negating self-
esteem
INDEPENDENT:

>Established therapeutic
nurse-client relationship,
conveying an
attitude of caring

>Assessed mental/physical
influence of condition on
the clients emotional
state

>Assessed clients current
level of adaptation and
progress

>Listen to clients
comments and responses
to the situation

>Encouraged positive
reinforcement

>Encouraged verbalization
of feelings



COLLABORATIVE:

>Used appropriate
communication
techniques

>Referred to appropriate
support groups.


>To establish trust and
baseline data



>To evaluate level of
clients knowledge &
anxiety related to situation


>To enhance acceptance



>To provide opportunities
for listening of concerns
and questions

>To continue to strive for
improvement

>To decreased level of
anxiety





>To gain accurate
information


>To enhance more of the
knowledge
SHORT-TERM:

After 8 hours of
nursing intervention,
the client was able to
verbalized
understanding of
body changes


LONG-TERM:

After 3 days of
nursing intervention,
the client was able to
recognized and
incorporate body
image change into
self-concept in
accurate manner
without negating self-
esteem
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
SMalaki na rin ang
binagsak ng timbang ko
kumpara dati kase di nako
nakakakain ng maayos
dahil na rin sa kundisyon
ko as verbalized by the
client.

O> Alert, conscious,
coherent

>Afebrile

>Oriented to time, place
and person

>Dry &poor skin turgor

>Capillary refill after 2-3
seconds

>Muscle strength of 5/5
on both upper and lower
extremities.

>weight loss (160 lbs-120
lbs within 6 months)

>NGT-Fecal drainage,
blood streaked stool (10-
20ml)

>Auscultated 5-6
borborygmic sound in
each quadrant for 1
minute.Tympany heard @
each quadrant

>V/S taken as follows: BP:
130/80,HR:78,RR:20,T:36
Risk for infection r/t
increased exposure to
environmental
exposure to
pathogens
SHORT-TERM:

After 8 hours of
nursing intervention,
the client will be able
to prevent or reduce
the risk of infection
such as fever,
inflammation, loss of
function, and redness

LONG-TERM:

After 3 days of
nursing intervention,
the client will be able
to demonstrate
techniques, lifestyle
changes to promote
safe environment.
INDEPENDENT:

>Established rapport and
Assessed general
condition

>Noted risk factors for
occurrence of infection

>Observed for localized
signs of infection at
insertion sites. Assess and
document skin conditions
around insertions of
drainage. Maintained
aseptic technique

> Encourage early
ambulation, deep
breathing, coughing,
position changes Q2

>Encouraged proper hand
washing

DEPENDENT:

>Administered
medications (antibiotics,
antivirals,etc.) as
prescribed by the doctors

COLLABORATIVE:

> Emphasized necessity of
PPE for all health care
team

>To gain trust and baseline
data



>To identify the source of
infection

> To decrease the risk of
further infection






> To promote mobilization
and prevention of
respiratory infection


>To eliminate the in
invading microorganisms



>To prevent occurring of
infection





>To fight the first-line
defense against
healthcare-associated
infections
SHORT-TERM:

After 8 hours of
nursing intervention,
the client was able to
prevent or reduce the
risk of infection such
as fever,
inflammation, loss of
function, and redness


LONG-TERM:

After 3 days of
nursing intervention,
the client was able to
demonstrated
techniques, lifestyle
changes to promote
safe environment