ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Diarrhea related to Release of SHORT TERM INDEPENDENT: SHORT TERM GOAL
“Madalas ako invasion of the enterotoxins by GOAL - Observe and record -To note for degree of
nadudume na may lining of the colon invading amount, fluid losses After implementation of
kasamang dugo at secondary to microorganism After 30-45 characteristics and appropriate nursing
medyo basa. infectious processes minutes of frequency of bowel intervention, the client was
Nakaramdam din as manifested by: nursing movement. able to promptly replaced
ako ng pagsusuka ACF of stool Increase intervention the -To replace fluid fluids and electrolyte
kung minsan at  2-3X/ day secretion of client will be - Increase oral fluid losses due to frequent losses through hydration
pananakit ng tiyan”  brownish water and able to promptly intake vowel movement and electrolyte
as verbalized by the yellow electrolytes replace fluids supplement as evidenced
patient with and - To assess for by increased in oral intake
blood electrolyte - Monitor intake and decrease in fluid and maintained electrolyte
Objective: streak, losses through output volume resulting to balance
ACF of stool loose and Inhibits the hydration and dehydration
 2-3X/ day mucoid sodium electrolyte - Goal fully met
 brownish  1 cup per reabsorption supplement as - Assess for signs of -To determine client’s
yellow with bout evident by dehydration hydration status and
blood streak,  Hyperactive increasing oral determine
loose and bowel fluid intake and dehydration
mucoid sounds Large amount of electrolyte DEPENDENT: LONG TERM GOAL
 1 cup per bout CHON rich fluids balances
 Hyperactive  Abdominal -Administer IV fluids as After implementation of
bowel sounds cramps LONG TERM indicated with -To replenish and appropriate nursing
 Abdominal Diarrhea GOAL electrolyte establish hydration intervention, the client was
cramps supplements (KCl) and maintain able partially reestablished
After 3-4 hours electrolyte balance hydration status as to
Inferences: nursing prevent dehydration
Fecalysis (08/16/08) Reference: intervention the -Administer through absence of signs
Presence of Medical Surgical client will be antiprotozoal -Inhibits nucleic acid of dehydration minimum
Entamoeba Nursing by Black able to medication (Flagyl) of the bacteria there intake and output
histolytica and Hokanson reestablish by eliminating spread
Result: Pg 1078-1079 hydration status of infection - Goal is partially met
Cyst = 1-3L/LPF as to prevent
Trophozoite= dehydration
1-2/LPF through physical
assessment and
careful
monitoring of
intake and
output.
ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Anxiety related Vague uneasy Within our 8 hour  Establish rapport  To gain trust and Within our 8 hour
“Worried ko sa to possible feeling of span of care, cooperation. span of care,
akong situation surgery discomfort or patient will be patient was able to
basig operahan secondary to dread able to  V/S taken and recorded.  Serves as baseline data. understand and
man gud ko”, as Acute accompanied by understand and demonstrate
verbalized by the Appendicitis. an autonomic demonstrate  Assess awareness of  Validate the feeling and positive coping
patient. response (the positive coping patient about anxiety. communicate acceptance of mechanism and
Objective: source often mechanism and the feelings. describe a
 Irritability nonspecific or describe a reduction in the
noted unknown to the reduction in the  Provide accurate  Helps the client to identify level of anxiety.
 Anxious individual); a level of anxiety. information to the client. what is reality based. Goal Met.
looking feeling of
 Discomfort apprehension  Provide comfort  To help the patient relax.
noted caused by measures.
 Restlessness anticipation of
noted danger it is an  Provide and maintain  Anxiety may escalate with
alerting signal quiet environment. excessive conversation,
that warns of noise and equipment about
impending the patient.
danger and
enables the
 Encourage patient to talk  Talking about anxiety
individual to take
about anxious feelings. producing situations and
measures to deal
anxious feelings can help the
with the threat.
person perceive the situation
(Gulanick/Myers
in less threatening manner.
Nursing Care
Plans, 6th
Edition)
ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Limited Having an After 8 hours of INDEPENDENT: After 8 hours of
“Anay, hinay movement Appendectomy is nursing  Instruct the client to  Activity that require nursing
hinay la ke ma ol- related to pain a procedure that interventions, the minimize activities that holding the breath and interventions the
ol tak samad” as as manifested has the need to patient will be will put pressure on his bearing down can result in patient is able to
verbalized by the by incision on cause the tissue able to regain / abdomen. pain to surgical site in Rest quietly Sit in
patient. RLQ. to be maintain mobility RLQ, bradycardia and a high-fowlers
traumatized, at the higher rebound tachycardia with position from
Objective: which leads to possible level, elevated BP. lying in bed, and
Temp - 36.6 oC the inflammatory Demonstrate  Reposition periodically know the proper
PR - 53 bpm process techniques that and slowly and encourage  Prevent / reduces way in seating
RR - 26 cpm characterized by enable deep breathing exercises. incidence of skin and from a supine
BP-110/70mmhg pain, redness, resumption of respiratory complications. position.
 weakness swelling and loss activities, and therefore:
 facial of function of Increase strength/  Encourage rest. GOAL MET
grimace some part, it is function of  Reduces myocardial
 guarding effective in the affected and workload / oxygen
behavior treatment of compensatory consumption, reducing
 incision on appendicitis with body parts. risk of complication.
RLQ perforation,  Move patient slowly and
surgery leaves deliberately.  Reduces muscle tension or
tissue damage guarding, which may help
that causes the minimize pain of
release of movement.
chemical
mediators, and  Administer analgesics as
WBC’s which ordered  To maintain “acceptable”
causes to form level in pain. Notify
exudates then physician if regimen is
this exudates inadequate to meet pain
causes the nerve control goal.
endings to be
compressed thus
making pain and
this pain makes a
person to have
limited
movement.

Reference:
Medical Surgical
nursing by
Brunner and
Suddarth 11th
edition; Vol.2
pages 1240-
1242