Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis Explanation Outcome

The patient Diarrhea related Diarrhea is a After 4 hours 1.Reviewed causative 1. To prevent SHORT TERM
manifested to condition of of nursing factors and reoccurrence. After 4 hours of
the following: gastrointestinal loose, watery interventions, appropriate nursing
S: SO bowel movement the patient will interventions. 2. To prevent bacterial interventions, the
infection
verbalized 4 lasting for a few verbalize growth and SO shall verbalize
episodes of secondary to understanding of
days. This understanding 2. Reviewed food contamination
diarrhea upon parasitic preparation, causative factors
admission infestation AEB condition is of causative and rationale for
emphasizing adequate 3. To prevent the
passing of loose caused by an factors and cooking time and treatment regimen.
spread of infectious
V/S as bowel infection in the rationale for proper storage or causes of diarrhea
follows: T- movements.
intestines due to treatment refrigeration. LONG TERM After
36.3°C, P- ingesting regimen. 4. Increased intake of two days of nursing
120bpm, parasites by 3. Emphasized the water will aid in interventions, the
consuming After two days importance of hand hydration. Intake of patient shall
RR-32 bpm.
contaminated of nursing hygiene. liquids containing maintain normal
food or water interventions, minerals and patterns of bowel
containing the patient will 4. Encouraged electrolyte can functioning.
harmful maintain increased oral fluid replenish those lost.
microorganisms. normal pattern intake.
of bowel 5. Bland, simple foods
functioning. 5. Encouraged intake are easier to digest
of non- spicy or and are less irritating
complex food, and to the bowel.
recommend bland
food, natural fiber, and
probiotics.
Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis Explanation Outcome

Patient Impaired tissue Impaired tissue After 4 hours of INDEPENDENT INDEPENDEN SHORT TERM
manifested integrity related integrity is the nursing 1. Applied T After 4 hours of
irritability in the to imbalanced damage to the interventions, the barrier dressings 1. To promote nursing
IV insertion site, nutritional state. mucous patient will or wound tissue healing. interventions,
facial grimaces, membrane, identify covering. the SO shall
and crying. corneal interventions 2. To protect identify
integumentary, appropriate to 2. Assisted with the wound, interventions
Presence of or promote healing. position reduce appropriate to
wounds. subcutaneous changes and infections, and promote
tissues.
After two days of simple exercise. enhance healing.
Ribs are nursing healing.
Factors that
prominent. interventions, the DEPENDENT LONG TERM
can cause
patient will DEPENDENT After two days
impaired tissue
display 1. Encouraged 1. To promote of nursing
V/S as follows: integrity progressive optimum circulation and interventions,
T- 36.3°C, P- include poor improvement in nutrition such as prevent the patient shall
120bpm, RR-32 nutrition and wounds or protein, lipids, excessive display
bpm. deficient fluid lesions. minerals and tissue pressure. progressive
intake. vitamins. improvement in
wounds or
lesions.
Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis Explanation Outcome

Patient Imbalanced Nutritional SHORT TERM 1. Determined 1. To identify SHORT TERM

manifested the nutrition: less imbalance is After 4 hours of lifestyle factors deviations from After 4 hours of
following: than body caused by the nursing that may affect the norm and to nursing
S: none requirements r/t inability of the interventions, imbalanced establish interventions,
O: Distended inability to body to absorb the SO must nutrition. baseline the SO shall
abdomen. absorb nutrients certain nutrients verbalize parameter. verbalize
2. Evaluated
secondary to or result from a understanding understanding
degree of deficit
Thin extremities parasitic poor diet and of causative and total daily 2. Helps of causative
and spinous infestation AEB even factors and food intake. determine factors and
process. low weight. infestations necessary nutritional necessary
from parasites interventions. 3. Suggested a needs. interventions.
Protruding rib that reduces the diet modification
cage and collar body’s LONG TERM with a nutritional 3. To establish LONG TERM
bone. capability to After two days plan that meets a nutritional After two days
absorb essential of nursing the clients need. plan that meets of nursing
V/S as follows: nutrients. interventions, the clients interventions,
T- 35.1°C, PR- the patient must 4. Emphasized to need. the patient shall
demonstrate S/O importance demonstrate
122 bpm, RR- of well-balanced,
changes to 4-5. Promotes changes to
36 bpm nutritional intake.
regain wellness and regain
appropriate provides appropriate
5. Developed
weight. realistic weight information weight.
goal of the client. regarding
nutritional
needs.
Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis Explanation Outcome
Patient Readiness for Enhanced SHORT TERM: 1. Assessed 1. Helps to SHORT TERM:
manifested the enhanced nutrient intake is After 1 hour of eating patterns identify specific After 1 hour of
following: nutrition. the desire to nursing and food and strengths and nursing
S: SO verbalized improve the interventions, fluid choices in weaknesses that interventions,
“gusto kong nutritional status the SO must relation to any can be the SO shall
palitan yung of the patient demonstrate health risk addressed. demonstrate
iniinom niya ng consuming food behaviors to factors and behaviors to
gatas” that does not attain health goals. 2. These factors attain
O: SO shows make the appropriate are constantly appropriate
willingness to needed weight gain. 2. Verified that presented weight gain.
enhance feeding requirements. age related and throughout the
Pattern of After 2-3 hours, developmental lifespan After 2-3 hours,
V/S as follows: healthy eating the SO must be needs are met although the SO shall be
means able to safely different from able to safely
T- 35.1°C, PR-
eating a variety prepare foods. 3. Assessed the age group prepare foods.
122 bpm, RR- of foods that SO’s ability to
36 bpm provide nutrients LONG TERM: safely store and 3. To determine LONG TERM:
that are After 1 week of prepare food if health After 1 week of
essential in nursing information or nursing
maintaining interventions, 4. Encouraged resources might interventions,
health and the patient must variety and be needed the patient shall
energy. gain 2 kg. moderation in gain 2 kg.
dietary plan 4. To encourage
SO to make
healthy choices
about eating and
food
Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis Explanation Outcome

The patient Deficient fluid Diarrhea is a SHORT TERM: INDEPENDEN T INDEPENDEN SHORT
manifested the volume related condition of After 4 hours of 1. Offered a T TERM: After
following: to excessive frequent loose, nursing variety of fluids 1. To increase 4 hours of
S: SO losses through watery bowel interventions, and water rich the client’s daily nursing
verbalized diarrhea. movement the SO must food, as well as fluid intake. interventions,
“dalawang lasting for a few verbalize assisting the the SO shall
beses na days. The body understanding client to drink as 2. To avoid verbalize
siyang tumae excretes too of causative needed. ‘ foods or understandin
magmula much water and factors and substances that g of causative
kanina” can result in appropriate 2. Provide for precipitate factors and
dehydration due interventions. changes in diarrhea. appropriate
O: Dry skin to fluid loss. dietary intake. interventions.
Patient refuses LONG TERM: 3. To promote
to drink water After two days 3. Recommend return to normal LONG
orally of nursing products such as bowel TERM: After
interventions, natural fiber and functioning. two days of
V/S as follows: the patient must yogurt. nursing
T- 36.3°C, P- maintain fluid DEPENDENT interventions,
120bpm, RR- volume at a DEPENDENT the patient
32 bpm. functional level, To increase the shall maintain
as evidenced 1. Provided client’s daily fluid volume
by good skin supplemental IV fluid intake at a
turgor. fluids as functional
indicated. level, as
evidenced by
2. Administered good skin
medication as turgor.
appropriate.
>F: Impaired tissue integrity related to imbalanced >F: Imbalanced nutrition: less than body requirements
nutritional state. related to inability to absorb nutrients, secondary to
parasitic infestation AEB low weight.
>D: Received PT lying on bed w/IVF of #8 500cc D5IMB
seen at 450cc level infusing well on right dorsal hand. V/S >D: Received PT awake, carried by mother on bedside.
as follows: T- 36.3°C, P-120bpm, RR-32 bpm. Patient PT is hooked with D5IMB#6 500cc @ 25ml infusing well @
manifests irritability in the IV insertion site, presence of 30cc/hr @ L dorsal hand, IV tubing secured w/no irritation.
wounds, ribs are prominent, facial grimaces, and crying. PT is warm to touch bilaterally, skin lesion at posterior
head. PT appears to have a distended abdomen,
>A: Monitored vital signs; regulated IV fluid; provided AM thin extremities and spinous process, and protruding rib
care, such as bedmaking and removing unnecessary cage and collar bone. V/S as follows: T- 35.1°C, PR-122
things on PT’s bed. Provided patient teaching about bpm, RR-36 bpm.
nutrition, specifically protein. Established rapport. Checked
the IV site insertion. Provided patient teaching about
proper hygiene. Provided comfort, such as back rub. >A: Monitored vital signs; regulated IV fluid; provided AM
care. Determined lifestyle factors that may affect
>R: The PT’s S/O manifested understanding about the imbalanced nutrition. Evaluated degree of deficit and total
teachings given. daily food intake. Suggested a diet modification with a
nutritional plan that meets the clients need. Emphasized to
S/O importance of well-balanced, nutritional intake.
Developed realistic weight goal of the client.

>R: S/O verbalized understanding of the patient teaching

and necessary interventions.