ASSESSMENT DIAGNOSIS PLANNING INTERVETION RATIONALE EVALUATION

SUBJECTIVE: Hyperthermia related -After 30 minutes of Independent: GOAL MET

“Nilalagnat po ako simula to disease condition nursing intervention -Monitor temperature -To determine After the necessary nursing
kagabi hanggang kaninang as evidenced by the temperature of every 10 minutes and underlying cause and interventions, the patient was
umaga” as verbalized by the increase of temp the client will be if there is presence of appropriate able to decrease the
patient. (38.9°C) reduced from 38.9 °C chills. interventions temperature from 38.9°C to
to 37.0°C 37.0°C
-Encourage the -To replace loss of
OBJECTIVE: -After 30 minutes of patient to increase fluids by means of
- Temperature: 38.9 °C nursing interventions fluid intake sweating or rapid
- Skin is warm to the patient’s skin will breathing
touch be cool to touch
- Heart Rate: 106 bpm -If the patient is
- Respiratory Rate: 22 -After 30 minutes of -Adjust and monitor having chills give
cpm nursing interventions environmental factors them blankets to
the patient can that may affect warm them up if they
demonstrate patient’s temperature are sweating
behaviors to monitor like room profusely provide
and promote temperature, more ventilation.
normothermia ventilation, light for
comfort, and noise.
-By means of
-Perform Tepid evaporation it can
Sponge Bath help cool down the
skin more providing
comfort for the
patient
Dependent:
-Administer -To minimize
antipyretics as complications and
prescribed by the reduces temperature
physician
ASSESSMENT DIAGNOSIS PLANNING INTERVETION RATIONALE EVALUATION
SUBJECTIVE: Ineffective tissue Short Term: Independent: GOAL MET
“Nahihilo at perfusion related -After 20 minutes -Obtain resting vital signs. -To have baseline data and to After 20 minutes of
nanghihina sya” as to reduced of nursing assess changes nursing interventions
verbalized by the cellular intervention the the patient was able to
S/O. components that patient will be able -Regularly check for the capillary -To assess if there is demonstrate relaxation
are essential to to demonstrate refill and conjunctiva for changes peripheral perfusion technique without any
OBJECTIVE: deliver pure relaxation supervision of the
Physical oxygen to the technique to -Elevate head of bed to 30 ° -To promote blood health care provider.
Assessment: cells, as maximize circulation
-Pale skin evidenced by low circulation -Help the patient to develop a self-
-Pale Nail Beds hemoglobin, care plan that includes relaxation -To provide the patient with
-Pale Conjunctiva RBC, and Long Term: techniques and aid in maintaining a practical tools to enhance
Lab Results: hematocrit. -After 2-3 days of healthy lifestyle self-awareness and facilitate
-Hemoglobin = 39 nursing a healthy lifestyle
g/L interventions the -Perform GCS and monitor for any
REF: 130-180 patient will be able changes -To detect any possible
-Red Blood Cells = to gradually cerebral perfusion
1.6 X10^12L improve tissue Dependent:
REF: 4.6-6.0 perfusion as -Provide or maintain oxygen as -Aids in the matched supply
-Hematocrit = 0.12 evidenced by pink ordered and demand of oxygen
REF: 0.40-0.54 conjunctiva and
nail beds. -Coordinate with other health care -To monitor levels of
professionals for CBC monitoring Hemoglobin, Red Blood
-Increase in Cells, and Hematocrit.
Hemoglobin, Red
Blood Cells, and
Hematocrit to aid
in the delivery of
oxygen
ASSESSMENT DIAGNOSIS PLANNING INTERVETION RATIONALE EVALUATION
SUBJECTIVE: Decreased Short Term: Independent: GOAL MET
“Hindi sya active sa activity -After 30 minutes -Obtain resting vital signs. -To have baseline data and to After 30 minutes of
school kasi mabilis tolerance – 1 hour of assess changes necessary nursing
sya mapagod dahil related to nursing interventions the
sa sakit nya” as imbalance intervention the -Encourage the patient to perform light -Determines the nursing patient willingly
verbalized by the between patient will be activities such as walking or doing light intervention needed to assist the participated and will
S/O. oxygen supply able to identify chores (ADL) and providing assistance patient be able to verbalize
and demand as alternative ways as necessary. the importance pf
OBJECTIVE: evidenced by to maintain maintaining a
-Heart Rate: 106 visible desired activity -Note changes in patient’s gait/ balance -To ensure that the patient is not desirable activity
bpm tiredness level over exerting with the activity level
-The patient has
visible tiredness Long Term: -Monitor the patient’s vital signs -To be aware of changes
-Pallor -After 8-10 hours throughout the instructed activity
-Difficulty in of nursing
engaging in interventions the -Provide a quiet atmosphere for the -Rest lowers the body’s oxygen
activities patient may report patient’s rest and sleep requirements
measurable
increase in Provide Health teachings on the
activity tolerance. importance of:
-Prioritization of activities -Promotes adequate rest and
-participates maintains energy level
willingly in
necessary or -Energy saving techniques such as -Encourage patient to perform
desired activities sitting when performing tasks activities while avoiding fatigue

-Activity progression as tolerated -Encourage gradual return to

normal activity level
 -Adequate rest periods in between -Prevents fatigue
activities

ASSESSMENT DIAGNOSIS PLANNING INTERVETION RATIONALE EVALUATION

SUBJECTIVE: Ineffective coping Short Term: -Build rapport with the patient -For the patient to easily GOAL MET
“Nag kukulong po related to -after 15-30 open up to you After 15-30 minutes of
ako sa kwarto ko inadequate minutes of nursing nursing interventions
kapag na i-istress confidence in intervention the -Determine understanding of -Identifies coping skills that the patient verbalized
ako” as verbalized ability to deal patient will be able current situation, previous, and may be used in present effective coping
by the patient. with the situation to verbalize other methods of coping with situations strategies.
as evidenced by effective coping problems
OBJECTIVE: defensiveness and strategies -May help the patient begin
The patient’s mood changes -Encourage verbalization of to come to terms with long
responsiveness when Long Term: feelings and fear unresolved issues
asked about a -After 2 days of
specific question nursing -Family members who are
about his disease he interventions the -Observe for strengths such as the coping with critical illness
becomes defensive patient will meet ability to relate facts and to often feel defeated, hopeless,
and is visibly sad psychological acknowledge the source of the and like a failure; therefore,
needs as evidenced stressor it is necessary to verbally
by appropriate praise them for their
expression of strengths and use those
feelings, strengths to aid in
identification of functioning
options and use of
resources.