Date/ Cues Need Nursing Objectives of Care Nursing Intervention Evaluation
Time Diagnosis
10 Subjective: Knowledge After 4 hours of 1. Establish rapport. Goal Met!
deficit nursing intervention /23 C ® to gain patient’s trust and have a 10/23/19 regarding my patient will be good nurse-patient relationship /19 “Wala ko kabalo asa O condition, and able to know and @ gikan ning akong treatment understand the G related to disease process and 6:00pm hepatitis, wala pud absence of treatment regimen 2. Evaluate desire/readiness of @ gani ko kabalo unsa N information as evidenced by: patient to learn. na.” I After 4 hours of ® determine amount or level of my nursing 2:00 T information to provide at any given a.) Participate intervention my “Katong nagsakit ko moment. pm I in learning patient was able sauna kay ® Deficient to know and nagpadoctor ko ato V process knowledge is a understand the unia naa man to mga 3. Provide an atmosphere of respect, E state in which b.) verbalization possible diseases tambal, tapos openness, trust, and collaboration. cognitive of and treatment nagkasakit napud ko - information or understandi ® important when providing regimen as mga pila ka bulan, psychomotor ng about his education to patients with different evidenced by: mao to gbalik lang P skills required disease values and beliefs about health and nako ug tumar tong E for health process illness. mga tambal pero recovery, a.)patient wala nako R c.) initiation of maintenance, participated in nagpacheck up ug lifestyle C or health 4. Assess motivation and willingness learning process usab.” changes and promotion are of patient and caregivers to learn E participate As verbalized by the lacking. in treatment ® some patient are ready to learn as patient P regimen soon after they are diagnosed; others T cope better by denying or delaying b.) “Ah. Kabalo the need for instruction nako kung diin na Objective: U makuha ang A infection kung 5. Assess history of hepatitis b hindi ka maninlo - Lack of L sang kalawaswan infection source of mo.” As P information ® to trace the source of infection verbalized by the A patient - Asked questions T 6. Be alert to signs of avoidance regarding his condition T c.) “Dapat kung ® May need to allow client to suffer E consequences of lack of knowledge mag masakit ko, - Expresses magpa-check up before client is ready to accept confusion on R ko dayon sa information. the nature of doctor kag hindi the condition N ko magpataka - Denial of 7. Discuss patient’s perception of lang inom bulong condition need na wala man gin resita sang akon - Purchase of ® Relate information to patient’s doctor.” As over the personal desires/needs and values or verbalized by the counter beliefs. patient drugs without consulting 8. State objectives clearly in learner’s the physician term
® to meet learner’s need according to
level of understanding 9. Participate in learning process