ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

S- Maglisod sijag ginhawa

mam as verbalized by the
mother



O- dyspneic

- Tachypnea noted
with RR of 60
cpm, irregular
and shallow


- Irritability noted
- Restlessness
noted
- Lethargic
- Pallor




Altered breathing pattern
r/t decreased lung
expansion secondary to
intra-abdominal fluid
collection (ascites)

SB:
Edema in the form of
ascites, besides
compressing and thus
affects its functions, may
also cause shallow
breathing and impaired
gas exchange resulting in
respiratory compromise.

After 8 hours of nursing
interventions patient will
be relieved from dyspnea
and breathing pattern will
return to normal.

.Monitor respiratory rate,
rhythm and depth





Auscultate breath sounds,
noting crackles, wheezes
and rhonchi


Investigate changes in LOC



Keep head of bed
elevated. Position at sides


Keep head elevated during
feeding.

Provide supplemental O2
as indicated


Rapid shallow
respirations/dyspnea may
be present because of
hypoxia or fluid
accumulation in the
abdomen

Indicates developing
complications and
increasing risk of
infections

Changes in mentation may
reflect hypoxemia and
respiratory failure

Facilitates breathing by
reducing pressure in
diaphragm

To eliminate chances of
regurgitation or aspiration.

May be necessary to
treat/prevent hypoxia.












ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

S- din a man sija ganahan
mu.totoy lagi, unja ug mo
totoy kay ginagmay ra pod
kaajo as verbalized by
mother


O-less intake of food
(breast milk)

-weight of 6.7 kg

-poor sucking reflex

Imbalanced nutrition less
than body requirements
r/t improper absorption of
nutrients.

After 8 hours of nursing
interventions patient will
manifest no signs of
ineffective nutrition.

Patients mother will be
able to identify different
recommended or
prescribed nutritious
foods that can be given to
the child.

Monitor vital signs


Obtain initial weight and
monitor daily.


Regulate IVF as prescribed


Recommend/provide small
frequent meals




Promote undisturbed rest
periods, especially before
meals.


Enumerate foods
recommended for the
supplemental feeding
appropriate for patients
age.




Serves as baseline date


Shows progress on the
status of the child


For fluid and electrolyte
replacements

Poor tolerance to larger
meals may be due to
increased intra-abdominal
pressure/ascites


Conserving energy reduces
metabolic demands on the
liver and promotes cellular
regeneration.

Giving of appropriate
supplemental foods may
hinder the chance of
having idigestion, allergies,
etc.










ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
S- gamay man cja man,
gamaya pud cja ug
timbang as verbalized by
mother


O- weight of 6.7 kg
-small build for age

Altered growth related to
chronic illness.


SB:
Delayed or slower than
expected growth can be
caused by many different
things, including chronic
illness, endocrine health,
infection, poor nutrition.
Many child with delayed
growth also have delays in
development.
Long term goal:
After a month the infant
grows following growth
curve while maintaining
appropriate nutritional
status.

Specifically
-the infant will be able to:

1. Show indications
of normal child
growth and
development for
a 7 month old
child like rolling
over, sits with
support, and
grasps and
mouths object.



Monitor weight on regular
basis




Assess caretakers
knowledge, resources,
support systems, coping
skills and level of
commitment

Perform nutritional
assessment





Asses caregiver issues








To have a growth curve
monitoring.




To develop a plan of care





Overfeeding or
malnutrition on a constant
basis prevent child from
reaching healthy growth
potential, even if no
disorder/disease exists

This could impact clients
ability to thrive




ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
S-nagkalibang jud cja mao
amo giadmt nalaman as
verbalized by mother



O- passage of watery
stools for more than 3
times
-hyperactive bowel sound
-poor skin turgor
-signs of severe
dehydration noted
-capillary refill time more
than 2 seconds
-dry lips and mucosa

Fluid and electrolyte
imbalance related to
frequent passage of loose
watery stools


SB:
Electrolytes are chemical
in the body that regulate
important physiological
functions and include
sodium, chloride,
magnesium, potassium
and calcium. When
dissolved in water,
electrolytes separate into
positively and negatively
charged ions. Nerve and
muscle functions are
dependent upon the
proper exchange of these.
This must exist in the body
within a narrow
concentration range in
order to effectively serve a
variety or critical functions
Long term goal:

-After 1-2 days of nursing
interventions, the patient
will reestablish and
maintain normal pattern
of bowel functioning AEB
passage of semi-solid
stools


Short term goal:
After 8 hours of nursing
interventions:

-the patients mother will
verbalize understanding of
causative factors and
rationale for treatment
regimen.

1. Establish rapport
2. Assess general
condition and vital
signs
3. Auscultate abdomen
4. Discuss the different
causative factors and
rationale for
treatment regimen
5. Restrict solid food
intake
6. Provide for changes
in dietary intake
7. Limit caffeine and
high-fiber foods and
so as fatty foods
8. Promote use of
relaxation technique
9. Encourage oral fluid
intake of fluids
containing electrolyte
10. Emphasize
importance of hand
washing
1. To gain patients
mother s trust
2. For baseline data
3. For presence,
location, and
characteristics of
bowel sounds
4. For patient education
5. To allow for bowel
rest and reduce
intestinal workload
6. To allow
foods/substances
that precipitate
diarrhea
7. To prevent gastric
irritation
8. To decrease stress
and anxiety
9. For fluid replacement
10.To prevent spread of
infectious diseases























ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S- gihilantan man sija
mam as verbalized by
mother


O- temp of 38.9
-flushed skin and warm
to touch
-dry mucos membrane
Hyperthermia related to
increased metabolic rate
After 8hours of nursing
interventions patient will
be able to:

-Maintain core temp.
within normal range 36.5
to 37.5
Note chronological and
developmental age of
client





Note presence or absence
of sweating as body
attempts to increase heat
loss by evaporation,
conduction and diffusion,




Provide Tepid Sponge
bath.
Promote surface cooling
by means of undressing,
cool environment using
fans.




Administer medications as
indicated/prescribed (e.g
antipyretic)

Administer replacement
fluids and electrolytes


Instruct parents to not
leave child alone

Discuss importance of
adequate fluid intake

Children are more
susceptible to heatstroke;
elderly or impaired
individuals may not be
able to recognize and/or
act on symptoms of
hyperthermia

Evaporation is decreased
by environmental factors
of high humidity and high
ambient temperature, as
well as body factore
producing loss of ability to
sweat or sweat gland
dysfunction.

Heat loss by radiation and
conduction, heat loss by
convection, heat loss by
evaporation. Note that
alcohol spongebaths are
contraindicated because
they increase peripheral
vascular constriction and
CNS depression.

To treat underlying cause



To support circulating
volume and tissue
perfusion

To prevent injury


To prevent dehydration