Assessment Diagnosis Planning Intervention Rationale Evaluation

Cues: Excess fluid WIthin 8 hours of - Monitor the vital signs - To obtain baseline data After 8 hours of nursing
 Edema volume nursing intervention of the patient and general condition of intervention the patient
 Skin taut, related to the patient the patient. significant other will be able
shiny underlying significant other will to verbalize understanding
health be able to verbalize - Monitor intake and - Provide status information of individual dietary and
condition understanding of output. to establish the fluid monitoring of intake and
individual dietary balance fluid needs output as evidence by:
and monitoring of replacement. “Bantayan na nako iyang
intake and output. kinaon ug iyang gi-ihi o gi-
- Provide or recommend - Obtaining and utilizing libang”
balanced nutrition electrolytes and other
minerals depends on client Goal Met
regularly receiving them
in a readily available form.

- Assess neuromuscular - To evaluate for presence

reflex of electrolyte imbalance

- Review the laboratory - To evaluate degree of fluid

results for abnormal and electrolyte imbalance.
findings.

- Elevate edematous - Reduce tissue pressure and

extremities, change risk skin breakdown.
position frequently

- Place in semi-Fowler’s - To facilitate movement of

position , as diaphragm, thus
appropriate improving respiratory
effort
- Emphasize need for
mobility and/or - To prevent stasis and
frequent position reduce risk of tissue
changes. injury.
Assessment Diagnosis Planning Intervention
Cues: Impaired comfort related Within 8 hours of nursing DEPENDENT
Subjective Cues to illness related symptoms intervention the patient’s - Determine the type
“Gi-alimootan lang sya significant other will be of discomfort the
day.” As verbalized by able to engage in behaviors patient is
significant others or lifestyle changes to experiencing, such
Objective Cues: increase level of ease. as physical pain or
- Drowsy feeling of
- Weak discomfort.
- Restless - Monitor VS
- Diaphoretic
- Fanning
-Discuss
interventions/activit
ies such as
therapeutic touch,
massage; play
therapy and humor.
- Provide age-
appropriate comfort
measures
- Teach client and
significant other about
the non-pharmacologic
ways to lessen the pain.
INDEPENDENT
- Encourage
significant others to
let the patient have
an adequate rest
periods.
- Encourage age-
Rationale Evaluation
Within 8 hours of
- A comfort scale nursing intervention the
can help patient patient’s significant
identify focus of other will be able to
discomfort. engage in behaviors or
lifestyle changes to
increase level of ease of
the patient as evidenced
- To look by the significant others
for significant “ Medyo okay na gamay
changes in vital iya pamati day.”
signs Goal Met.
- To provide
nonpharmacologica
l pain management.
- To promote ease
and relaxation and
to refocus attention.
- To maximize
opportunities for se
lf-control over pain
manifestations.
- To prevent fatigue.
- To alleviate
 appropriate patient’s
diversional discomfort.
activities (e.g., play
time, games, and
socialization).

- Instruct significant - To decrease

others to provide physical discomfort
routine position associated with bed
changes. rest ad also ensure
good circulation.
- Advise significant - To boost patient’s
others to let the body resistance to
patient eat fruits infections that may
and vegetables. lead to further
complications.
- Instruct significant - Body needs 3.5 L
others to let the of water daily as
patient have an the body has
adequate fluid sensible and
intake as tolerated. insensible water
losses. More water
intake aids in the
recovery and
prevents
dehydration.