Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Short-term goals: Independent: • To ascertain Short term goal:

Imbalanced treatments/interventions
Subjective cues: nutrition: After 30 minutes of • Assess eating After 30 minutes of
that may be needed in
less than appropriate nursing patterns and appropriate nursing
The patient stated addition to weight
body intervention, the food/fluid choices in intervention, the
that management
requirement patient will: relation to any patient has:
“Hindi ako s related to health-risk factors
electrolyte • Have an • Verbalized
masyadong and health goals.
imbalance as adequate adequate
makagalaw,
evidence by knowledge • Provide information knowledge in
nanhihina ako” • Helps client determine
muscle on the foods regarding poor the foods to
nutritional needs.
weakness to enhance dietary habits. enhance his
Objective: his nutrition • To assist client in finding nutrition and
• Encourage client to
and food healthy options and to have food that
• Muscle choose nutritious
that need to balance electrolyte need to be
weakness foods such
be avoided. avoided.
(+) vegetables, fruits
• Verbalize and low-fat foods. • Verbalized
• Low commitment commitment
potassium • Encourage client to
mutually  To assist client in adopting mutually
3.36 eliminate food that
agree upon healthy eating habits agree upon
is rich in fats, spicy
• Low Ionized goals and goals and
foods and
calcium treatment treatment
cholesterol and
plan plan
0.96 discuss its
purpose/impact
• High
triglycerides GOAL HAS
Long-term goal: Dependent: BEEN MET
(2.94)  Medications or supplements
After 2 weeks of • Give medication and
 • Spoon fed appropriate nursing vitamins to the to replace electrolytes. Long-term goal:
by the intervention, the patient as ordered
After 2 weeks of
nurses patient will:
appropriate nursing
• Colostomy • demonstrate intervention, the
Collaborative:
bag in RLQ proper  To evaluate effective patient has:
weight gain  Collaborate with nutritional program and
• Weight loss • Demonstrated
that is physician or dietitian have adequate nutrition
proper weight
proportion or nutrition team
gain that is
to his height  To evaluate if the
proportion to
and age intervention is helpful or the
his height and
 Follow up clinical care need to be adjusted.
• Demonstrate age
chemistry as
an increase
ordered • Demonstrated
in muscle
an increase in
strength and
muscle
perform
strength and
simple ADL
perform
simple ADL

GOAL HAS NOT MET

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Short-term goals: Independent: Short term goal:
Risk for
Subjective cues: infection After 30 minutes of • Monitor vital signs such  Timely monitoring of BP
related to appropriate nursing as BP and temperature and temperature help to
surgical GOAL
intervention, the early detect if there is a
Objective: wound in HAS BEEN
patient will: presence of sepsis
colostomy, MET
• High
intrajugular • Patient
neutrophils
catherization verbalizes • Maintain strict asepsis
79 and  The aseptic technique Long-term goal:
understandin for dressing changes,
exploratory decreases the chances of
• Low g of wound care, intravenous
transmitting or spreading
lymphocytes laparotomy behavioral therapy, and catheter
pathogens to or between GOAL HAS NOT
6.0 and hygiene handling.
clients. Interrupting the MET
measures to
• High chain of infection
prevent
Eonsiphlils effectively prevents the
infection.
12.0 spread of infection
• Patient will
reduce the  The first sign of a stoma
risk of  Inspect the stoma and infection may be a pus-like
infecting the surrounding skin. discharge, unusual swelling,
surgical increasing redness, or color
wound changes.

 Encourage sleep and  Adequate sleep is an

rest. essential modulator of
Long-term goal: immune responses. A lack
of sleep can weaken
immunity and increase
susceptibility to infection.
  Hand washing protects
patient from sources of
 Promote good
infection
handwashing
procedures by staff and
visitors. and limit
visitors

Dependent:

 Monitoring WBC,
Collaborative: neutrophils and
lymphocytes determine if
 Monitor CBC of the there are possible presence
patient of infection