Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
S: “di ako masyado Imbalanced After 8 hours of v/s taken and *in order to get the  Patient verbalize
makakaen” as Nutrition: Less nursing recorded baseline data understanding of
verbalized by the pt. than body intervention the importance of
O: requirements r/t pt will balance nutrition
 Slightly Pale in inadequate food verbalized I and O monitored * Determination of  Demonstrates
appearance intake understanding amount of fluid behavior
 Decreased the importance Encourage intake and output. changes to
subcutaneous of proper verbalization of *to know the regain
fats nutrition and feelings perception of client appropriate
 Poor skin turgor exercise weight
 Weak in Kept safe and  Able to ingest
appearance comfortable in bed *in order to avoid increase fluid
 Limited ROM accidents intake and foods
 Lack of appetite Reinforced rich in vitamins.
adequate rest  Able to consume
 BP=100/70
period *to regain energy Recommended
T=36.7
and to avoid Daily
P=90
straining Allowances
R=18
Referred to (RDA)
dietitian for further  Still pale in
assessment and *Dietitians have a appearance, poor
recommendations greater skin torpor.
regarding food understanding of
preferences and the nutritional value
nutritional support of foods and may be
helpful in assessing
Facilitated proper specific ethnic or
position while cultural foods
eating and
observed SAP. *Elevating the head
of bed 30 degrees
 aids in swallowing
Provided good oral and reduces risk of
hygiene aspiration.
*in order to give
comfort to the
patient through
Provide feeling clean and
companionship fresh
during mealtime. * Attention to the
social aspects of
eating is important
in both the hospital
Encouraged to and home settings.
increase fluid * Supplemental
intake at least 8 nutrition, to
glasses of water a enhance wound
day and eat foods healing and regain
reach in protein, energy.
carbohydrates, and
vitamins.

Discourage
beverages that are * These may
caffeinated or decrease appetite
carbonated. and lead to early
satiety.
Encouraged
ambulation and * Metabolism and
passive Rom utilization of
nutrients are
enhanced by
Health teaching activity.
rendered:
  The basic
four food * Foods high in
groups, as calories and protein
well as the that will promote
need for weight gain and
specific nitrogen balance
minerals or
vitamins.

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
S:”masakit yung era ko Risk for After 8 hours of v/s taken and *to get baseline  Patient
” as verbalized by the pt. infection r/t nursing recorded data verbalized
post intervention the pt understand ways
O: debridement will understand Maintain clean *to avoid invasion on preventing
 Weak in ways on technique in cleaning of microorganisms infection and
appearance preventing and changing the ways to reduce
 Poor muscle tone infection and to wound dressing. further
 With wound reduce further complication.
dressing on left complication Instructed to perform *To promote  Able to
foot with elactic passive ROM proper circulation demonstrate
bandage and proper colostomy
soiled by pus Instructed client to care and hand
limit visitors * This reduces the washing
number of  Verbalized
organisms in understanding
patient’s the importance
environment and of proper
restricts visitation hygiene and
 by individuals with identified s/sx of
any type of infection.
infection to reduce  Still weak in
the transmission of appearance
pathogens to the
patient at risk for
infection.

*to assess the

Observed for any signs of infection
untoward s/sx such
as redness, swelling,
increased pain.

Encourage intake of *This maintains

protein- and calorie- optimal nutritional
rich foods. status.

*These measures
Encourage coughing reduce stasis of
and deep breathing; secretions in the
consider use of lungs and
incentive spirometer. bronchial tree.
When stasis
occurs, pathogens
can cause upper
respiratory
infections,
including
pneumonia.
Health teaching *To lessen
given: microorganisms;
 Teach patient Patients and
and caregivers can
significant spread infection
others to from one part of
wash hands the body to
often, another, as well as
especially pick up surface
after pathogens; hand
toileting, washing reduces
before meals, these risks.
and before
and after
administering
self-care.

 Teach patient
the signs and *To give
symptoms of immediate
infection, and intervention
when to
report these
to the
physician or
nurse.

* To lessen
 Reviewed microorganisms
importance of
proper
hygiene
CHRISTINE GRACE PONCIANO
BSN-III-C
GROUP 15 SUBMITTED
TO:
MRS. CHRISTINE
BELTRAN