ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE NURSING EVALUATION
THEORY
Subjective: Activity Intolerance After nursing Independent: GOAL PARTIALLY
intervention the MET
“Nagapangluya siya Related to: patient will a.) Evaluate client’s a.) Establishes Dorothy Johnson
kag indi siya mayad General weakness demonstrate a response to activity. patient’s After nursing
kahulag” as and imbalance measurable Note reports of capabilities / needs (Human Behavioral intervention the
verbalize by the between oxygen increase in dyspnea, increased and facilitates System) patient were able to
folks. supply and tolerance to activity weakness / fatigue, choice of demonstrate
demand. with absence of an changes in vital interventions. - This theory measurable
Objective: lethargy and signs during and focuses on the increase in
excessive fatigue, after activities. balance to maintain tolerance to activity,
- Lethargy and vital signs stability in the but not totally. Vital
- Verbal within client’s system. It also signs within client’s
reports of acceptable range. focuses on the acceptable range.
weakness behavior of the
- Fatigue patient threatened
- Exhaustion with illness. Also in
the medicines that
the patient is
receiving.
b.)Provide a quite
environmental and b.) Reduces stress Florence
limit visitors during and excess Nightingale
acute phase as stimulation,
indicated. promoting rest. (Environment
Encourage use of theory)
stress management
and diversional - Organizing and
activities as manipulating
appropriate. environment
(physical, social,
and psychosocial)
in order to put the
person in the best
condition alleviate
unnecessary pain
c.) Explain c.) Bed rest is and suffering.
importance of rest in maintained during
treatment plan and acute phase to Dorothy Johnson
necessity for decrease metabolic
balancing activities demands, thus (Human Behavioral
with rest. conserving energy System)
for healing. Activity
restrictions - This theory
thereafter are focuses on the
determined by balance to maintain
individual client stability in the
response to activity system. It also
and resolution of focuses on the
respiratory behavior of the
insufficiency. patient threatened
d.) Assist patient to with illness.
assume comfortable d.) Patient may be
position for rest / comfortable with
sleep. the head of bed Ida Jean Orlando
elevated, sleeping
in a chair, or (Nursing Process –
leaning forward on ADPIE)
overboard table
with pillow support. - Nurses can help
the patient what
they cannot do to
their self.
- Exploring the
meaning of the
need and validating
g.) Assist with self – the effectiveness of
care activities as g.) Minimizes the action.
necessary. Provide exhaustion and
for progressive helps balance Ida Jean Orlando
increase in activities oxygen supply and
during recovery demand. (Nursing Process –
phase. ADPIE)
- Nurses can help
the patient what
they cannot do to
their self.
- Exploring the
meaning of the
need and validating
the effectiveness of
the action.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE NURSING THEORY EVALUATION
Subjective: Ineffective Airway - After 8 Independent: GOAL MET
Clearance hours of
“Gina ubo siya” nursing a.) Monitor Vital a.) To asses Dorothy Johnson - After the
As verbalized by the related to: intervention signs every baseline end of the
folks. the patient hours. data of the (Human Behavioral shift, the
-Increased sputum will be able patient. System) patient is
Objective: production in to cough - This theory able to
response to effectively focuses on the cough
- Inability to respiratory and clear balance to maintain effectively
cough infection. secretions. stability in the and clear
effectively - After 8 system. It also secretions.
- Anxiety -Decreased hours of focuses on the - After the
- Dyspnea energy, fatigue duty the behavior of the end of the
- Dry cough patient will patient threatened shift, the
display with illness. patient
patent b.) Position display
airway with patient in a b.) To promote Ida Jean Orlando patent
breath moderated maximal lung airway with
sounds high position function. (Nursing Process – breath
clearing, or semi ADPIE) sounds
absence of fowler’s - Nurses can clearing,
dyspnea. position. help the absence of
patient what dyspnea.
c.) Turn patient they cannot
every two c.) For do to their
hours and repositioning self.
PRN. , it promotes - Exploring the
drainage of meaning of
pulmonary the need and
secretions validating the
and it effectiveness
enhances of the action.
ventilation to
decrease
potential of
atelectasis.
d.) Provide oral Virginia Henderson
care. d.) Secretions
from CAP (14 components of
are often foul Nursing Care)
tasting and - Nurses will do
smelling. what the things
Providing that patients
oral care cannot do.
may - From
decrease dependence to
nausea and independence.
vomiting
associated
with the taste
of
e.) Instruct secretions. Hildegarde Peplau
patient or the
folks (Basic care
regarding e.) Promotes components
medications, prompt - Orientation,
side effects, identification Identification,
and of potential Exploitation
symptoms of adverse & Resolution.
adverse reaction to
reaction to facilitate
report to the timely
nurse or intervention.
physician.
Dependent: Lydia Hall
a. Administer
medication (Component of
such as a.) A variety of Nursing Care)
antibiotics medications
and are available - Care, Core and
expectorants to treat Cure.
for specific - Through medicines
productive problems. the patient can be
cough. cured and infection
can be cured.
b. Instruct the
patient or the
folks to notify b.) It may
nurse if the indicate
patient is bronchial
experiencing tubes are
shortness of blocked with
breath or air mucus,
hunger. leading to
hypoxia and
hypoxemia.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE NURSING EVALUATION
THEORY
Subjective: Risk for less than After nursing Independent: GOAL MET
body requirements intervention the
“Wala siya mayad patient will a.) Provide covered a.) Eliminates Virginia Henderson After nursing
nagakaon, wala Related to: demonstrate a container for sputum noxious sights, intervention the
gana” as verbalize measurable and remove at tastes, smells from (14 components of patient were able to
by the folks. - Increased increase in appetite frequent intervals. the patient Nursing Care) demonstrate
metabolic needs and can tolerate Assist with / environment and - Nurses will do measurable
Objective: her OTF of 1,500 encourage oral can reduce nausea. what the things increase in appetite
- Abdominal kilocalories per hygiene after that patients and can tolerate her
Sodium – 136.3 distension / gas day / 6 (250 cc of emesis, after cannot do. feeding.
associated with OTF per feeding) aerosol and postural
- Starvation swallowing air drainage
- Diabetic acidosis during dyspneic treatments, and
- Dehydration episodes before meals.
Height: 152 cm b.) Bowel sounds Ida Jean Orlando
b.) Auscultate bowel may be diminished /
Weight: 44 kg
sounds. Observe / absent if the (Nursing Process –
BMI: 19.0 palpate fro infectious process is ADPIE)
abdominal sever / prolonged.
distention. Abdominal - Nurses can help
distention may the patient what
occur as a result of they cannot do to
air swallowing or their self.
reflect the influence - Exploring the
of bacterial toxins meaning of the
on the need and validating
gastrointestinal the effectiveness of
tract. the action.
c.) Evaluate general c.) Presence of
nutritional state, chronic conditions
obtain baseline or financial
weight. limitations can
contribute to
malnutrition,
lowered resistance
to infection, and / or
delayed response to
therapy.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE NURSING THEORY EVALUATION
Subjective: Impaired Gas After 8 hours of Independent: GOAL PARTIALLY
Exchange duty, the patient MET
“Nabudlayan siya will improved a.) Observe a.) Cyan Hildegarde Peplau
mag ginhawa” related to: ventilation and color of skin, osis of nail beds After 8 hours of
As verbalized by the oxygenation of mucous may represent (Basic care duty, the patient
folks. -Altered oxygen- tissues by ABGs membranes, vasoconstriction components was able to
carrying capacity of within patient’s and nail beds, or the body’s - Orientation, improved
Objective: blood / release at acceptable range noting presence response to Identification, ventilation and
cellular level and absence of of peripheral fever / chills; Exploitation oxygenation of
- Tachycardia symptoms of cyanosis or however, & tissues by ABGs
- Restlessness -Altered delivery of respiratory central cyanosis of Resolution. within patient’s
- Dyspnea oxygen distress. cyanosis. earlobes, acceptable range
- Hypoxia (hypoventilation) mucous and absence of
membranes, symptoms of
and skin around respiratory distress.
the mouth is
indicative of pH - 7.45
systemic (7.35 – 7.45)
hypoxemia.
PCO2 - 41.3
b.) (35 – 45 mmHg)
b.) Assess Restlessness,
mental irritation, PO2 - 46.0 (80 – 100
status. confusion, and mmHg)
somnolence
may reflect HCO2 - 28.3
hypoxemia / (22 – 26 mmol/L)
decreased
cerebral TCO2 - 66.4
oxygenation.
Dorothy Johnson
c.) Monitor c.) Tachycardia is
heart rate / usually present as a (Human Behavioral
rhythm result of fever / System)
dehydration but - This theory
may represent a focuses on the
response to balance to maintain
hypoxemia. stability in the
system. It also
d.) High fever focuses on the
d.) Monitor greatly increases behavior of the
body metabolic demands patient threatened
temperature. and oxygen with illness.
Assist with consumption and
comfort alters cellular
measures to oxygenation.
reduce fever
and chills. e.) Prevents
overexhaustion and
e.) Maintain reduces oxygen
bedrest. consumption /
Encouirage demands to
use of facilitate resolution
relaxation of infection.
techniques
and
diversional
activities. f.) These measures Ida Jean Orlando
promotes maximal
f.) Elevate inspiration, enhance (Nursing Process –
head and expectorantion of ADPIE)
encourage secretions to - Nurses can help
frequent improve ventilation. the patient what
position they cannot do to
changes, their self.
deep - Exploring the
breathing, meaning of the need
and and validating the
ineffective effectiveness of the
coughing. action.
Dorothy Johnson
Dependent: a.) Follows
progress of (Human Behavioral
a.) Monitor ABGs disease process System)
and facilities - This theory
alterations in focuses on the
pulmonary balance to maintain
therapy stability in the
system. It also
focuses on the
behavior of the
patient threatened
with illness.
