VISION Republic of the Philippines MISSION

A premier university in historic Cavite State University shall provide

Cavite recognized for
CAVITE STATE UNIVERSITY excellent, equitable and relevant
excellence in the development Don Severino Delas Alas Campus educational opportunities in the arts,
of morally upright and globally Indang, Cavite science and technology through
competitive individuals. quality instruction and relevant
research and development activities.
It shall produce professional, skilled
and morally upright individuals for
global competitiveness.

College of Nursing
Client’s Initial: A.D. Age: 10 Gender: Female

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective Data Acute pain related Short Term Independent Short Term
“nahihirapan akong to presence of After 2 hours o  Built rapport  To gain trust After 2 hours of
umihi tas minsan infection in urinary nursing intervention  Acknowledge  Reduce nursing intervention
masakit” as verbalized tract area as the client will be the pain and defensive the client was to
by the client manifested by pain able to understand discomfort response, understand the
scale of 6/10 the causative factors experience by promote trust, causative factors
Objective Data that cause pain the client and enhances that cause pain
 (+) pain when  Demonstrate cooperation
urinating Long Term hot and cold with regimen Long Term
 Pain scale 6/10 After one week of compress to  Hot and cold After one week of
 (+) facial nursing intervention alleviate the compress nursing intervention
grimace the client will be pain promote the client was
 (+)frequent able to reduce the  Verbalize the relaxation reduced the pain
urinate small pain presence in causative  To enhance the presence in
amount of urinating factors that knowledge of urinating
urine result in pain the client to
Alteration in Short Term and prevent further Short Term
comfort: related to After 2 hours of discomfort complication After 2 hours of
presence of nursing intervention  Encourage the  To remove the nursing intervention
infection in urinary the client will be client to formation of the client was
tract area as able to identify increase fluid the crystalized identified factors
manifested by facial factors that can intake salt in the that can reduce
 grimace reduce discomfort urinary tract discomfort
Long Term area. Long Term
After 5 hours of After 5 hours of
nursing intervention nursing intervention
the client will be Dependent the client was
able to alleviate the  Administer  To maintain alleviated the
discomfort felt by analgesics, as “acceptable” discomfort felt by
the client indicated level of pain. the client
dosage as Notify the
Short Term prescribe by physician if Short Term
Risk of infection After 2 hours of the doctor regimen is After 2 hours of
related to presence nursing intervention  Discuss the inadequate to nursing intervention
pain in the the client will be importance of meet pain the client was
abdominal area able to identify not taking control goal. identified causative
secondary to UTI as causative factors antibiotics  Inappropriate factors that causes
manifested by pain that causes infection unless it is use of infection in urinary
when urinating in urinary tract area prescribe by antibiotics can tract area
Long Term the doctor. lead to Long Term
After one week of development of After one week of
nursing intervention Collaborative drug resistant nursing intervention
the client will be  Collaborate in strain or the client was
able to reduce the treatment of secondary reduced the
infection in urinary underlying infections infection in urinary
tract area condition or tract area
disease
process  Promote
causing pain alleviating and
and proactive therapeutic
management regimen for the
of pain. client.
 Provide for  Promotes
individualized active, rather
physical than passive,
therapy or role and
 exercise enhance sense
program of control

VISION Republic of the Philippines MISSION

A premier university in historic Cavite State University shall provide
Cavite recognized for
CAVITE STATE UNIVERSITY excellent, equitable and relevant
excellence in the development Don Severino Delas Alas Campus educational opportunities in the arts,
of morally upright and globally Indang, Cavite science and technology through
competitive individuals. quality instruction and relevant
research and development activities.
It shall produce professional, skilled

College of Nursing and morally upright individuals for

global competitiveness.
 Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Subjective Data Ineffective health Short Term Independent Short Term
“may kuto at lisa po management related After 2 hours of  Build rapport  To gain trust After 2 hours of
ako, nahawahan po to lack of nursing intervention  Ascertain the  This provides nursing intervention
ata ako” as information the client will be client’s a baseline so the client was
verbalized by the regarding proper able to understand knowledge and planning care understand the
client hygiene as the importance of understanding of can begin importance of
manifested by proper hygiene condition and where the proper hygiene
Objective Data infestation of lice Long Term treatment client is in Long Term
 (+) lice and and neat After 2 weeks of needs. relation to After 2 weeks of
neat Impaired skin nursing intervention  Promotes client condition or nursing intervention
 (+) small integrity related to the client will be participation in illness and the client was
wound in head infestation as able to remove the planning and current removed the
her hair manifested by infestation of lice evaluation regimen infestation of lice
 (+) itchiness presence of lice and and neat in her head process  These and neat in her head
 (-) comfort neat  Perform head enhances
when Alteration in Short Term inspection, commitment Short Term
scratching comfort: itchiness After 2 hours of assessing color, and promotes After 2 hours of
her head related to head nursing intervention surfaces competent nursing intervention
infestation as the client will be changes. self- the client was
manifested by able to understand  Verbalize the management, understand the
presence of lice and the importance of importance of optimizing importance of
neat proper caring of proper hygiene outcomes proper caring of
head and hair  Demonstrate  Systematic head and hair
Long Term proper bathing inspection can Long Term
After 2 weeks of  Encourage the identify After 2 weeks of
nursing intervention client to use lice developing nursing intervention
the client we be able alis shampoo problems and the client was not
to remove in promotes totally removed in
infestation of lice Dependent early infestation of lice
and neat in her hair  Encourage the intervention. and neat in her hair
 client to use  To prevent
Short Term shampoo with further Short Term
After 5 hours of anti -ice and complications After 5 hours of
nursing intervention neat like lice alis  To promote nursing intervention
the client will be prevention of the client was
able to reduce the infestation reduced the feeling
feeling of discomfort Collaborative of discomfort
 Identify home  It prevent
Long Term and community- further Long Term
After 2 weeks of based nursing infestation After 2 weeks of
nursing intervention services and promote nursing intervention
the client will proper the client was
verbalize fully free in hygiene verbalize fully free in
discomfort and discomfort and
absence of itchiness  For absence of itchiness
of head assessment, of head
follow-up care
and education
in the client’s
home

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective Data Deficient fluid volume
“hindi po ako malakas related to lack of
uminom ng tubig, information regarding
mga 3-4 na baso appropriate amount
lang” as verbalized by of fluid intake am
the client manifested by
 insufficient fluid
Objective Data intake
 3-4 glasses of
fluid volume Impaired skin
intake integrity related to
 (+) dry skin insufficient fluid
 (+) dry lips intake as manifested
 (+) slightly by dryness of skin and
dried mouth lips
 (+) sunken
eye balls
 Increased
body
temperature