ASSESSMENT NURSING OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Imbalance Goal: Independent: Goal: partially met as
“wala akong gana nutrition less than The client will Assess the client Provide a data manifested by the client
kumain pag minsan body requirements have a adequate dietary status about dietary ability to:
din na rin ako related to inability nutritional intake status
makakain kasi to ingest food as verbalize understanding of
sinusuka ko din at evidenced by Short-term Assess for factors Information about causative factors when
minsan din nausea and After 2 hours of contributing to altered other factors that known and necessary
pinagbabawalan vomiting. nursing nutritional intake may be altered to interventions
ako kumain ng intervention the (nausea and vomiting, promote adequate
doctor dahil sa client will be able depression) dietary intake is Verbalized that that the
aking kalagayan” to verbalize provided feeling of nausea and
As verbalized by understanding of vomiting is lessened
the client. causative factors Provide patient food Increased dietary
when known and preferences within intake is
Objective: necessary dietary restrictions encouraged Demonstrate that the
-restless interventions feeling of nausea and
vomiting is lessened.
-loss of appetite Verbalized that Promote intake of low Reduces source of
that the feeling of protein foods, low restricted food and
-nausea and nausea and salt, low fat high fiber providing proteins
vomiting vomiting is meals. for growth and
lessened (e.g. 1 cup of rice, 2 healing
-muscle weakness banana per meal)
Long-term:
-bipedal edema After 1 week of Limit the fluid intake
(with foot necrosis) nursing
intervention the
client will be able Instruct to avoid food Avoid the increase
to: that increases gastric of gastric motility
motility
Demonstrate (e.g. hot, cold, spicy,
lifestyle changes caffeinated
to regain and beverages)
maintain
appropriate weight
Promote a pleasant
relaxing environment
Demonstrate a including
progressive weight socialization when
gain toward goal possible

Demonstrate that Dependent:

the feeling of Administer
nausea and medications as
vomiting is indicated
lessened.
Provide and
implement dietary
modifications

Collaborative:
Consult a dietitian as
indicated

Discuss the rationale Promote pt.

of dietary restriction understanding
in relation to kidney about his
disease condition.
 ASSESSMENT NURSING OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Ineffective airway Goal: Independent: Goal met as the client
“madalas clearance related The client will Monitor rhythm, rate, Provide a basis for verbalized and manifest
nahihirapan ako to accumulation of improved the depth and effort of adequacy of condition:
huminga at parang fluid in the lungs airway patency respiration ventilation
sumisikip yung secondary to -improved and maintain a
dibdib ko” as pneumonia as Short term: Auscultate breath To identify if there patent airway
verbalized by the evidenced by After 4 hours of sounds noting for any are any presence
client. ( rapid nursing adventitious or of adventitious -verbalized that the DOB
respirations, nasal intervention the abnormal breath breath sounds experienced is lessen or
Objective: flaring, and client will be able sounds relieved
-restless adventitious to verbalized that
breath sounds) the DOB Elevate HOB every Enhancing -demonstrate techniques
-dyspneic experienced is two hours ventilation to both and behavior to maintain a
lessened or lung segments open clear airway
-pale skin color relieved
Position client Lying flat can -verbalized understanding
-difficulty in Long term: appropriately. cause abdominal about cause and
breathing After 1 week of (sitting position with organs to shift management regimen.
nursing head slightly flexed, toward the chest,
-difficulty in intervention the shoulders relaxed and crowding the lungs
vocalizing client will be able knees flexed) making it more
to: difficult to breath)
-nasal flaring noted
Demonstrate Encourage deep Deep breathing
-crackles heard behavior and breathing and promotes
upon auscultation techniques to controlled coughing oxygenation while
maintain a clear exercises controlled
-RR= 27 and patent airway. coughing
accomplished the
Verbalized closure of the
understanding glottis and the
about the cause explosive
and management expulsion of air in
regimen the lungs by the
work of abdominal
and chest muscles

Dependent:
Institute respiratory A variety of
treatments (e.g. O2 respiratory
therapy, nebulizer treatments may be
etc.) used to open
constricted
airways
Administer
prescribed
medications as
indicated

Collaborative:

Consult a respiratory
therapist

Diagnostic test such

as (chest x-ray, ABG
etc.)