Republic of the Philippines
ISABELA STATE UNIVERSITY
City of Ilagan Campus, Isabela
COLLEGE OF NURSING
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Imbalanced Nutrition: After 8 hours of nursing Monitor the Regular After 8 hours of nursing
“wala akong gana kumain” Less Than Body intervention the patient patient's food monitoring helps intervention the Goal is
as verbalized by the Requirements related to will: intake, weight identify trends partially met. The patient
patient. Imbalanced Nutrition: be free of any changes, and and make was able to:
Less Than Body indications of adherence to the necessary Partially free of
Objectives: Requirements related to malnutrition and meal plan. adjustments to any indications of
Fatigue hypermetabolic state and exhibit a stable the care plan. malnutrition and
Weight loss emotional distress as weight or Conduct a Provides a exhibit a stable
Weakness of evidenced by inadequate progressive comprehensive baseline weight or
muscle food intake and loss of weight increase assessment of the understanding of progressive
Vital signs: interest in food. toward a goal patient's their current weight increase
BP: 90/80 with normalized nutritional status, nutritional state. toward a goal
PR: 84 laboratory test including weight, This information with normalized
RR: 19 findings. height, body mass helps identify any laboratory test
SpO2: 95% explain an index (BMI), and deficiencies or findings.
Temp.: 36.6°C understanding of dietary habits. excesses in Partially explain
individualized nutrient intake. an understanding
barriers to a Assess the It is essential to of individualized
sufficient intake. patient's medical identify any barriers to a
participate in history, including underlying sufficient intake.
targeted any conditions conditions participated in
initiatives to that might contributing to targeted
enhance contribute to a their initiatives to
nutritional intake hypermetabolic hypermetabolic enhance
and stimulate state or emotional state or emotional nutritional intake
appetite. distress. distress. Certain and stimulate
medical appetite.
conditions can
affect metabolism
and appetite.
Evaluate the Identifying
patient's sources of stress
Republic of the Philippines
ISABELA STATE UNIVERSITY
City of Ilagan Campus, Isabela
COLLEGE OF NURSING
emotional well- can guide
being and mental interventions
health, and aimed at
inquire about any improving
stressors that emotional health
might affect their and eating
eating patterns. behaviors.
Collaborate with This collaborative
the medical team approach ensures
to determine the a holistic
underlying causes understanding of
of the the patient's
hypermetabolic condition and
state and facilitates
emotional coordinated care.
distress.
Consult with a Ensures that the
dietitian to patient's
develop a nutritional plan is
personalized evidence-based
nutritional plan and tailored to
that addresses the their specific
patient's specific needs and
needs and preferences.
preferences. Dietitians are
experts in
creating balanced
and personalized
meal plans.
Republic of the Philippines
ISABELA STATE UNIVERSITY
City of Ilagan Campus, Isabela
COLLEGE OF NURSING
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Fatigue related to stress After 8 hours of nursing Ask the patient to This aids in After 8 hours of nursing
“ nanghihina ako, palagi and poor physical intervention the patient will: rate their level of creating a plan to intervention the patient
akong kahit na wala condition as evidenced fatigue, deal with the was able to:
naman akopng by overwhelming lack Report feeling more preferably on a patient’s fatigue.
masiyadong ginagawa” as of energy. energized. numeric scale, Report feeling
verbalized by the patient. Perform activities of and identify the more energized.
daily living and take time of day when Perform activities
part in preferred it is the worst. of daily living
Objective: activities that are Encouraged Adequate intake and take part in
lethargic; lack of appropriate for their Adequate of nutrients and preferred
energy level of activity. Nutrition and fluids supports activities that are
disinterest in Identify basis of Hydration the body's energy appropriate for
surroundings fatigue and production and their level of
Vitals signs are taken: individual area of helps combat the activity.
BP: 90/80 control effects of stress. Identify basis of
PR: 84 Promote Regular Engaging in fatigue and
RR: 19 Physical Activity regular exercise individual area of
SpO2: 95% can improve control
Temp.: 36.6°C cardiovascular
health, increase
muscle strength,
and boost overall
energy.
Assessed vital To evaluate fluid
signs status and
cardiopulmonary
response to
activity.
Certain
Review medications
medication including
regimen/use. prescription
Republic of the Philippines
ISABELA STATE UNIVERSITY
City of Ilagan Campus, Isabela
COLLEGE OF NURSING
(especially beta-
adrenergic
blockers,
chemotherapy),
OTC, herbal
supplements, and
etc.. are known t
cause and/or
exacerbate
fatigue.
Republic of the Philippines
ISABELA STATE UNIVERSITY
City of Ilagan Campus, Isabela
COLLEGE OF NURSING
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Urinary after 8 hours of nursing Assess the helps identify after 8 hours of
“Palagi akong umiihi, Incontinence intervention the client frequency, potential nursing intervention
minsan di na ako related to loss of will: volume, and triggers, the client was able to:
nakaka-abot sa bladder control as Verbalized circumstances contributing Verbalized
baniyo” as verbalized evidenced by understanding of surrounding factors, and understanding
by the patient. leakage of urine, condition. incontinence provides a of condition.
sudden urges to Report increase episodes. baseline for Report
Objective: urinate, and interval between evaluating the increase
Frequent increase in urine urge and effectiveness interval
leakage of frequency involuntary loss of between urge
small amount of urine interventions. and
of urine Provide
Void 3-4 hours in information on Educating the involuntary
Little or no individually patient about loss of urine
maintaining
warning when appropriate proper fluid Void 3-4 hours
adequate fluid
needing to amounts intake and in individually
intake and
urinate avoiding appropriate
avoiding
Vital signs are bladder amounts
bladder
followed: irritants helps
BP: 90/80
irritants like
caffeine and them make
PR: 84
alcohol. dietary choices
RR: 19
SpO2: 95%
that support
Teach and bladder health.
Temp.: 36.6°C
encourage the Kegel
patient to exercises can
perform Kegel improve the
exercises to patient's
Republic of the Philippines
ISABELA STATE UNIVERSITY
City of Ilagan Campus, Isabela
COLLEGE OF NURSING
strengthen ability to
pelvic floor control urine
muscles and flow and
improve reduce
bladder involuntary
control. leakage.
Encourage the A voiding
patient to keep diary helps
a record of identify
fluid intake, patterns,
voiding triggers, and
patterns, and potential
incontinence correlations
episodes to between fluid
identify intake,
triggers. urgency, and
incontinence
episodes.
Collaborate It ensures that
with a dietitian the patient
to assess and maintains
adjust the hydration
patient's fluid without
intake based exacerbating
on their incontinence.
specific needs
and lifestyle.
