ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Long Term: Short Term:

“ Hirap akong Sleep Deprivation After 8 hours of - Assess V/S > For baseline After 1 hour of
makatulog sa gabi,” related to nursing data nursing intervention,
as verbalized by the inadequate daytime intervention, the - Determine patient’s > Provides the patient was able
patient. activity. patient will be able usual sleep pattern & comparative to verbalize
to report expectations baseline understanding of
Objective: improvement in sleep problem.
- restlessness sleep pattern. - Recommend quiet > To reduce
- irritability activities, such as stimulation so Long Term:
- inability to Short Term: reading or listening to patient can relax After 8 hours of
concentrate After 1 hour of music nursing intervention,
nursing intervention the client was able to
the patient will be - Suggest abstaining > Because they report improvement
able to verbalize from daytime naps impair ability to in sleep pattern.
understanding of sleep at night
sleep problem.
- Ecourage patient to > The factors are
plan & restrict known to disrupt
caffeine & other sleep patterns
stimulating substance
late afternoon or
night meals
Assessment Diagnosis Planning Implementation Rationale Evaluation
Subjective: Acute pain related Short term: To Evaluate clients response to pain: Short term:
- “Sakit nang tiyan ko to After 2-4 hours > Obtain client’s assessment of pain to > To rule out worsening of After 2-4
ngayon” as verbalized gastroenteritis of nursing include location, duration, frequency underlying condition/ hours of
by the patient. as manifested by interventions, quality, intensity and precipitating factors. development of nursing
Guarding the patient will complications interventions,
behavior. be able to To assist client to explore methods for the patient was
facial grimace. report pain alleviation of pain: able to report
Objective: sleep disturbance relieved or > Provide comfort measures like nurse’s pain relieved
- Guarding behavior. restlessness.. controlled. presence, repositioning, touch, heat/cold > To promote non or controlled.
-facial grimace irritability packs. pharmacological pain
-sleep disturbance Pain scale of 7/10 Long Term: management. Long Term:
-restlessness . After 6-8hrs of > Instruct in the usage of relaxation After 6-8hrs of
- Pain scale of 7/10 nursing techniques such as deep/focused > To distract attention and nursing
-irritability interventions, breathing, imaging, music/TV reduce tension interventions,
the patient will the patient was
be able to > Encourage verbalization of pain when able to
verbalize that felt > To reduce concern of the verbalize that
the pain was unknown and associated the pain was
decrease from muscle tension decrease from
7/10 to 4/10 To promote wellness (teaching/discharge 7/10 to 4/10
considerations): > To prevent fatigue and
> Encourage adequate rest periods promote relaxation and
Medication: recuperation.
>Administer medications as prescribed by
the physician. > to facilitate fast healing.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Hyperthermia After 4-6 hours of -Monitor patient -Fever pattern After nursing
“Mainit ang related to nursing intervention, temperature may aids in intervention, the
pakiramdam ko” increased the patient will be degree and diagnosing patient was maintain
as verbalized by metabolic maintain the body patterns. underlying the body temperature
patient. rate, illness. temperature within disease. within normal range
normal range from from 37.8 to 37.
Objective: 37.8 to 37.
Flushed skin,
warmed to -Wash hands with -Reduces cross
touch anti-bacterial contamination
Restlessness. soap before and and prevents
after each care of the spread of
V/S taken as activity and infection.
follows: encourage proper
T: 37.8 hygiene. -May help
P: 80 reduce fever.
R: 21 -Provide tepid Use of ice
Bp: 120/80 sponge baths and water and
avoid the use of alcohol may
ice water and cause chills and
alcohol. can elevate
temperature.

-Used to reduce
-Administer fever by its
antipyretics central action
as on the
prescribed. hypothalamus.

-to prevent possible

dehydration

-Increased fluid intake