Assessment Nursing Scientific Rationale Objectives Nursing Intervention Rationale Evaluation

Diagnosis
Subjective : Imbalanced The body is like a After a series of 1. Note real, exact 1. These
“dire magana hiya Nutrition : less machine that needs to Nursing intervention, weight; do not anthropomorphic
na nakaon, than body be supplied with the the patient will able to estimate. assessments are
nawawarayan requirements right kind and amount demonstrate vital that they need
hiyagana pagkaon” may be related of fuel. This may refer stabilized weight or to be accurate.
as verbalized by the to inability to to nutrition or the food gain toward usual/ These will be used
SO. absorb nutrients requirements of a desired range with as basis for caloric
Objective : as evidenced by person or patient. normal laboratory and nutrient
 Weight loss Weight loss, Adequate nutrition is values after 1week of requirements.
 Weakness weakness, essential to meet the nursing. Intervention.
 Fatigue fatigue, poor body’s demands. 2. Take a nutritional 2. Family members
 Poor muscle muscle tone Several diseases can history with the may provide more
tone greatly affect the participation of accurate details on
 vs taken as nutritional status of an significant others the patient’s eating
follows individual, this includes habits, especially if
T-36.4 gastrointestinal patient has altered
P- 122bpm malabsorption, burns, perception.
R- 30cpm cancer; physical factors
Bp100/60mmHG (e.g., muscle weakness, 3. Ascertain etiological 3. Several factors may
poor dentition, activity factors for decreased affect the patient’s
intolerance, p[ain, nutritional intake. nutritional intake, so
substance abuse); social it is vital to assess
factors (e.g., economic properly. Patients
status, financial with dentition
constraint); problems need
psychological factors referral to a dentist,
(e.g., boredom, whereas patients
dementia, depression). with memory losses
In certain conditions may need service
such as trauma, sepsis, like Meals on
surgery, and burns, Wheels. Other
adequate nutrition is medications also
vital to healing and have an effect on
recovery. Also, religious the appetite of the
and cultural factors patient.
greatly influence the
food habits of patients. 4. Review laboratory 4. Laboratory tests
Imbalanced values that indicate play a significant
Nutrition: Less Than well-being or part in determining
Body Requirements in deterioration the patient’s
women exhibit a higher nutritional status.
incidence regarding An abnormal value
voluntary restriction of in a single diagnostic
food intake secondary study may have
to anorexia, bulimia, many possible
and self-constructed fad causes.
dieting. A pregnant
woman who has eating 5. Look for physical signs 5. The patient
problems may also have of poor nutritional encountering
problems like fetal intake. nutritional
growth restriction. deficiencies may
Older patients who resemble to be
have cognitive sluggish and
impairments and fatigued. Other
encounter financial manifestations
limitations have higher include decreased
chances of eating attention span,
problems. This includes confused, pale and
negligence, physical dry skin, dull and
limitations, brittle hair, and red,
deterioration of their swollen tongue and
senses, reduction of mucous
gastric secretion, poor membranes. Vital
digestion, and social signs may show
isolation and boredom tachycardia and
that cause lack of elevated BP.
interest in eating.
 Assessment Nursing Scientific Rationale Objectives Nursing Intervention Rationale Evaluation
Diagnosis
Subjective: Risk For Fluid Although often After a series of 1. Reduce infection 1. All caregivers must
“ Naka 20 hiya volume Deficit considered a benign Nursing intervention, transmission wear gowns; gloves
nag sinuka” as related to disease, acute the patient will: are used when
verbalized by vomiting gastroenteritis remains a -Control of diarrhea. handling articles
the SO major cause of morbidity -Minimized risk for contaminated with
and mortality in children infection. feces; place
Objective: around the world, -Maintained good skin contaminated linens
-20x vomiting accounting for 1.34 condition. and clothing in
-dry and million deaths annually -Improved hydration specially marked
cracked lips in children younger than and nutritional intake. containers to be
5 years, or roughly 15% -Satisfied sucking processed according
of all child deaths. needs in the infant. to facility policy;
Diarrhea may be mild, -Eliminated risk of visitors are limited to
accompanied by slight infection transmission. family only; teach
dehydration, or it may be the family caregivers
extremely severe, the principles of
requiring prompt and aseptic technique
effective treatment. and observe them;
and good
handwashing must
be carried out.
2. Promote skin integrity 2. To reduce irritation
and excoriation of
the buttocks and
genital area, cleanse
those areas
frequently and apply
a soothing protective
preparation such as
lanolin A or D
ointment; change
diapers as quickly as
possible, and placing
disposable pads
 under the infant can
facilitate easy and
frequent changing.
3. Maintain adequate 3. Weigh the child daily
nutrition on the same scale;
take measurements
in the early morning
before the morning
feeding; monitor the
intake and output
strictly; good mouth
care is essential
when the child is
NPO; when oral
fluids are started,
the child is given oral
replacement
solutions; after the
child tolerates these
solutions, half-
strength formula
may be introduced.
4. Maintain body 4. Monitor vital signs at
temperature. least every 2 hours if
there is fever; follow
appropriate
procedures for fever
reduction, and
administer
antipyretics and
antibiotics as
prescribed.
 Assessment Nursing Scientific Rationale Objectives Nursing Intervention Rationale Evaluation
Diagnosis
Subjective Abdominal Pain Acute pain can have a The following are the 1. Perform a 1. Assessment is the
“Maulul pa it related to sudden or slow onset common nursing care comprehensive first step in
iya tiyan kunu, underlying cause with an intensity ranging planning goals and assessment, assess managing pain. It
dida ha may secondary to from mild to severe. It expected outcomes for location, helps ensure the pt.
surok surok” Acute can happen after a Acute Pain: characteristics, onset, receives pain relief.
As verbalized by Gastroenteritis medical procedure, duration, frequency,
the patient surgery, trauma or acute Patient describes and severity of pain.
illness. It has a duration satisfactory pain 2. Observe non0verbal 2. Some patients may
Objective: of less than 6 months. control at a level less indicators of pain, deny the existence
-Slightly For pain to be classified than 3 to 4 on a rating moaning guarding, of pain. These
Abdominal as chronic, the patient scale of 0 to 10. crying and facial behaviors can help
Guarding needs to be experiencing Patient displays grimace with proper
it for more than 6 improved well-being evaluation of pain.
months. Its intensity can such as baseline levels
range from mild to for pulse, BP, 3. Anticipate the need for 3. It can even reduce
extremely incapacitating. respirations, and pain management the total amount of
In some cases: relaxed muscle tone or analgesia required.
Chronic pain has two body posture. 4. Provide a quiet
subcategories: malignant Patient uses environment. 4. Additional stressors
and non-malignant. pharmacological and can intensify
Malignant refers to non-pharmacological patient’s perception
pain associated with pain-relief strategies. and tolerance of
cancer and other Patient displays pain.
progressive diseases. improvement in mood, 5. Use non-
Non-malignant chronic coping. pharmacologic pain 5. Works by increasing
pain, on the other hand, relief methods the release of
refers to pain that (relaxation, exercise, endorphins, boosting
persists beyond the breathing exercise and the therapeutic
expected time of healing. music therapy effects of pain relief
medications.