Nursing

Assessment Rationale Desired Outcome Interventions Justification Evaluation

Diagnosis

Subjective: Activity intolerance After 3 hours of Independent: After 2 days of nursing

Predispos Precipitati
related to nursing interventions, interventions, the patient
Indi ko kaya ing ng Factors:
generalized the patient will be was able to:
mag giho kung Factors:
weakness/ limited Low able to:
wala may 1. Monitor and 1. To obtain the
physical activity as Female socioecono
gabulig sa record vital baseline data.
evidenced by mic status
akon as signs. 1. Goal met.
difficulty moving Aged 36
verbalzed by 1. State the
without assistance Low She verbalized her
the patient. Multiparity importance of
educational 2. To facilitate fast reflection about the
early
attainment 2. Encourage early recovery. importance of early
With 5 ambulation.
ambulation. ambulation after health
Definition: children Lack of
Objective: teaching administered by
support
3. To provide nurse.
system at
3. Provide health adequate
The state in which
Weakness teaching about knowledge
an individual is not
Post-operative CS with bilateral the importance concerning 2. Goal met.
capable of doing
Restlessnes tubal ligation of early immobility.
activities of daily
s ambulation She expressed
living due to her 2. Participate and especially willingness to participate
Physical condition, muscle perform
Stress standing and in physical activities by
weakness or physical 4. To prevent
Inactivity walking. performing exercises like
fatigue. activities. overexertion.
sitting and walking.
Exertional Lethargy/Weakness
discomfort
4. Assist client with
Source: Restlessness
With D5LR activities such
1L (IVF) at as:
left 3. Goal met.
Activity intolerance related to
metacarpal Nurses Pocket generalized weakness/ limited Improved mobility
vein Guide Diagnoses, physical activity as evidenced by Move from one through progressing the
Prioritized difficulty moving without 3. Enhance her
side of the bed to physical exertion like
Interventions, and assistance personal functions in
the other side. sitting and walking.
Rationales; 13th ambulation and doing
 edition by Marilynn activities of daily Move from bed to
E. Doenges, Mary living. chair
Frances 5. In order the
Moorhouse, Alice Walk in the patient will be
Vital Signs: hallways able to get up
C. Murr
slowly and
easily.
BP= 160/130 5. Let patient sit on
mmHg bed; then let
her dangle her 6. To be aware of
PR= 88 bpm
legs for a few patients
RR= 27 cpm minutes; then extent of
let her stand on movement
Temp= 36.7 C her feet. difficulty.

6. Encourage
verbalization of
feelings 7. To protect
regarding client from
movement injury.
limitations.

8. To familiarize
7. Promote comfort self of
measures. adequate
energy
reserves
required for
8. Assess nutritional activity.
status.

9. To increase
patients self-
confidence and self-
esteem.
 9. Involve the patient
and significant others
in goal setting and care
planning.

Assessment Nursing Rationale Desired Outcomes Nursing Rationale Evaluation

Diagnosis Interventions

Subjective: Decreased After 2 days of nursing Independent: Independent: After 2 days of nursing
Predisposin Predisposin
cardiac interventions, the interventions, the client
Taas ang BP niya g Factors: g Factors: 1. Monitor and check 1. To serve as baseline data
output client will be able to: was able to:
halin kagab-e related to vital signs
Female Low
wala ganubo sa decreased 1. Identify her acordingly. 1. Goal met.
socioeconmic
160 as venous Aged 36 current health
status 2. Regulate IVF and 2. To avoid circulatory She reflects on her
verbalized by return level status.
check for overload current health status by
patients as Multiparity Low
signigicant other patency. verbalizing nagtaas akon
evidenced educational 3. To determine fluid shifts or
With 5 BP, tani manubo na
by BP of attainment 3. Assess urine signs of urinary
children
160/130 output; monitor incontinence.
Objective: mmHg how often the
4. To assist patient in 2. Goal met.
Maternal Constitutional Factors: patient urinates.
UA Result: 2. Engage in identifying and acquiring
behaviors or 4. Explain drug knowledge regarding Engaged in behaviors or
Client is hypertensive and has
 (+) Definition: history of Eclampsia activities to regimen, prescribed drug. actions to improve her
Proteinuria improve her purpose, dose current health status such
Patient with seventh pregnancy (28 current health and side effects. as maintaining bed rest in
Dizziness 2/7 AOG) status. order to facilitate early
The state in
recovery.
Oxygen at 2 which an
individual Collaborative: Collaborative:
cpm via nasal Abnormal Development or Poor
cannula experiences Placentation
1. Maintain optimal 1. To help evaluate client's
a reduction
fluid balance. fluid and electrolyte
Slight edema in the Oxidative Stress
balance
in both hands amount of 2. Maintain adequate
blood Defective invasion of the spiral
ventilation and 2. To prevent for signs of
Decreased pumped by arteries by cytotrophoblast cells
perfusion, as in poor ventricular
urine output the heart,
Endothelial Activation/Dysfunction the following: function, poor organ
resulting in functions and in the
Anxiety,
compromise Spasm of veins Place patient in event of impending
Restlessness
d cardiac semi- to high- cardiac failure
Tachypnea function. Abnormal Placental Development Fowlers
and Reduced Perfusion to organs position.
Increased
Diffusion of blood from bloodstream Place patient in
uric acid
into interstitial tissue supine position
Increased Source: Edema Administer
Lactate
dehydrogena humidified
Decreased cardiac output related to
se oxygen as
decreased venous return level as
Nurses ordered
evidenced by BP of 160/130 mmHg
Pocket Guide
3. Maintain physical
Diagnoses,
and emotional 3. To helps lessen
Prioritized
rest and sympathetic
Intervention
Vital signs: emotional rest, stimulation physical
s, and
as in the stress/tension;
BP=160/130 Rationales;
following: promotes relaxation
mmHg 13th edition
by Marilynn Provide quiet,
PR= 88 bpm E. Doenges, relaxed
Mary environment
RR= 27 cpm Frances
Moorhouse, Organize
Temp= 36.7 C Alice C. Murr nursing and
medical care.
Capillary refill =

more than one

second

Assessment Nursing Rationale Desired Outcome Nursing Interventions Justifications Evaluation

Diagnosis
Subjective Risk for Female (G7P6(4204), Elementary After 2 days of nurse Independent: After 2 days of nurse
G7P6(4204) ineffective Graduate, Low Socioeconomic client interaction Health Teaching on: client interaction client
Age of mother: Therapeutic Status client will be able to was able to show:
36 with Regimen show:
History of Management 1. Prescribed 1. To teach client the 1. Goal Met:
Eclampsia and related to Knowledge Deficit 1. Willingness to Medication by need to comply to Client was able to
Hypertension insufficient learn about the doctor. her medications in answer the correct
With five knowledge of and show Especially order to lessen the frequency, dosage and
children and dietary Financial Constraints active Nifedipine to risk of route of the drug. Was
currently a requirements, participation lower High Blood complications or able to verbalize the
housewife lack of in treatment Pressure. more severe effect of the drug Ga pa
awareness of Non-compliance to therapeutic plan and care illnesses nubo sang Blood
An
current Regimen Pressure
Elementary-
condition, and
level graduate
lack of financial 2. Verbalize 2. Nutritional 2. To help client plan 2. Goal Met:
Budlayan ko
resources. Risk for ineffective Therapeutic statements planning. (to eat foods that is right Patient recognized the
 mag maintain Regimen Management related to reflecting low cholesterol for her condition. need to exchange her
sang bulong Definition: insufficient knowledge of dietary ways to and low sodium habits. Verbalized Sakto
ko, isa pa gid Pattern in requirements, lack of awareness modify foods) gid na nga mag bago ta
ka rason ang which a person of current condition, and lack of personal para sa kaayuhan sang
kwarta as experiences or financial resources. habits and kaugalingon ta
verbalized by is at risk to integrate
the patient. experience treatments
Patient takes difficulty into lifestyle 3. To have variety and
maintenance integrating into 3. Preparation of as well as cost 3. Goal Met:
Nifedipine daily living a 3. Verbalize variety and cost effective food that Patient was able to
but with program for statements effective diet still provides good verbalize the risks (e.g.
lapses or treatment of reflecting an plans. amount of Diabetes, Ischemia,
inconsistency illness and the understandin nutrients. Heart attack)
sequelae of g of the
Objective illness that implications
Observed that meets specific of not
patient is able health goals. following the
to choose prescribed 4. To prevent any form
appropriate Source: treatment 4. Instructed of infection and 4. Goal Met:
foods but is Nurses Pocket plan. constant injury to the Client was able to
confused Guide hygienic wound surgical site and enumerate the
about the diet Diagnoses, 4. Answer to care. other parts of the appropriate kind of
correlating to Prioritized particular body foods.
her condition. Interventions, questions Answered Ang hindi
Observed and Rationales; concerning 5. To constantly check mantikaon kag hindi
patient does 13th edition by treatment 5. Instructed the progress of her maasin na pagkaon
not deal Marilynn E especially on patient to have condition
current Doenges, Mary nutrition and constant check-
conditions as Frances diet. up. 6. To lower or lessen
an importance Moorhouse, the risks of severe
in affecting Alice C, Murr. 6. Instructed client cardiovascular
her well-being. to perform light diseases and other
to moderate relatable diseases.
exercises e.g.
(walking) 7. To lessen the stress
and feeling of
overworking in
7. Help in taking care of
identifying children.
support systems
to lessen the
burden of taking
care of all five
children at home
which may
constitutes to
stress.