ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATI

ON
S: Wala akong Imbalanced After 2 days - Discussed eating -To appeal to clients After 2 days
ganang kumain nutrition: less of nursing habits, including food tastes of nursing
at wala pang than body interventions, preferences, intervention
kalahating plato requirements the patient intolerances or s, the
ng pagkain related to will aversions - Improved displayed
nauubos ko kasi increased demonstrate nutrition/diet is vital good
pakiramdam ko pressure on behaviors, - to recovery. Patient appetite
busog ako, as stomach and lifestyle Assisted/encouraged may eat better if and
verbalized by the intestines as changes to patient to eat; family is involved and interest in
client. feeling of regain and explain reasons for preferred foods are food by
O: fullness, poor maintain the types of diet. included as much as eating
- abdominal appetite as appropriate Feed patient if tiring possible almost of
enlargement evidenced by weight easily, or have SO his food.
(abdominal girth body weakness assist patient.
of 95cm) and poor muscle Consider preferences - Poor tolerance to
- poor muscle tone in food choices larger meals may be
tone due to increased
- weakness - intra-abdominal
- weight loss Recommended/provi pressure/ascites
- rbc 3.71 (low) ded small, frequent
- hgb 104 (low) meals - To enhance food
- BMI: intake
underweight
weight: 52 kilos
height: 17.9 - Promoted pleasant,
relaxing
environment, - Patient is prone to
including sore and/or bleeding
 socialization when gums and bad taste
possible in mouth, which
contributes to
- Encouraged anorexia
frequent mouth care,
especially before
meals

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S
S: May time na Ineffective After 30 minutes - Auscultated - Indicates Within 30
hinahabol ko ang Breathing of nursing breath sounds, developing minutes of
paghinga ko, Pattern r/t interventions, noting crackles, complications nursing
katulad ngayon pressure on the the client will wheezes, interventions,
as verbalized by diaphragm establish a rhonchi. the client has
the client. caused by intra- normal, effective - Facilitates established a
O: abdominal fluid respiratory - Kept head of breathing by normal,
- Rapid shallow collection as pattern bed elevated reducing pressure effective
respirations evidenced by on the diaphragm respiratory
-Shortness of rapid shallow - Encouraged -Aids in lung pattern as
breath respirations, and frequent expansion and evidenced by a
- Orthopnea orthopnea repositioning mobilizing decrease in
-Use of and deep- secretions respiratory rate
accessory breathing of 24 to 19
muscles to exercises/coughi
breathe ng as
- RR: 24 appropriate
- Reveals changes
- Monitored vital in respiratory
signs status, developing
pulmonary
complications.

-Changes in
- Investigated mentation may
changes in level reflect hypoxemia
of and respiratory
consciousness. failure, which
often accompany
hepatic coma.
-
ASSESSMENT BACKGROUND DIAGNOSI PLANNING INTERVENTIONS RATIONALE EVALUATI
S ON
S: Nag mamanas Ascites is the Fluid After 3 days -Weigh daily or on -Weight is the After 3 days
po mga paa ko at term used to volume of nursing a regular most accurate of nursing
nag-simula lumaki denote a fluid deficit r/t interventio schedule, as measure of intervention
tyan ko apat na collection in the compromis ns, the indicated fluid status s, the
buwan ng peritoneal ed clients - Reflects patients
nakakaraan, as cavity. Most regulatory fluid -Measure intake circulating fluid
verbalized by the commonly, mechanism volume will and output fluid volume volume has
client. ascites is due secondary improve as accurately status, improved
O: to liver disease to evidenced developing within
- weak in and the impaired by reduced fluid shifts, clients
appearance inability of that liver signs of normal
- abdominal organ to function as edema and limits, and
enlargement(abdom produce manifested decrease in - To evaluate a decrease
inal girth of 95cm) enough protein by weak in abdominal -Review lab data degree of fluid in
-decreased skin to retain fluid in appearanc girth (eg., BUN/Crea, and electrolyte abdominal
turgor the e, serum albumin, imbalance and girth from
-VS: bloodstream. decreased proteins and response to 99cm to
BP: 130-90 Normally, water skin turgor, electrolyltes;urine therapies 93cm
RR: 20 is held in the ascites and specific gravity) - Protein is
PR: 102 bloodstream by bipedal -Discuss metabolized
- urine specific oncotic edema importance of low into urea
gravity: 1.020 pressure. The protein intake and - For changes
- weight: 52 kg pull of proteins low salt intake that may
keeps water -Measure indicate
molecules from abdominal girth increasing
leaking out of regularly fluid retention
the capillary -Administer in the 3rd
blood vessels diuretics as space -
into ordered
surrounding
tissues. As liver
disease
advances, its
ability to
manufacture