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Goal Was Partially Met

The client reported difficulty sleeping due to pain in the perineal area from a recent surgery and usually only eating fish, meat, and green vegetables. Upon assessment, the client appeared lethargic, pale, and reported a pain level of 6/10 in the perineal area. The plan was to teach the importance of adequate bedrest and ways to improve sleep, as well as educate on nutrition and increasing vegetable intake to address imbalances. Nursing interventions included establishing rapport, assessments, and teaching about proper rest, sleep hygiene, nutrition, vitamins and avoiding junk food. After 30-60 minutes, the client could verbalize the importance of rest and ways to improve sleep, meeting the goal

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69 views3 pages

Goal Was Partially Met

The client reported difficulty sleeping due to pain in the perineal area from a recent surgery and usually only eating fish, meat, and green vegetables. Upon assessment, the client appeared lethargic, pale, and reported a pain level of 6/10 in the perineal area. The plan was to teach the importance of adequate bedrest and ways to improve sleep, as well as educate on nutrition and increasing vegetable intake to address imbalances. Nursing interventions included establishing rapport, assessments, and teaching about proper rest, sleep hygiene, nutrition, vitamins and avoiding junk food. After 30-60 minutes, the client could verbalize the importance of rest and ways to improve sleep, meeting the goal

Uploaded by

mcengrace23
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Problem #2

Cues/data Nursing
Diagnose
Planning Intervention Rationale Evaluation
Subjective
data:

Client stated
that
nahihirapan
po akong
makatulog kasi
nasakit ung
inoperahan sa
akin

kalimitan po e

Objective data:

-Positive
lethargic

-Positive pallor

-Pain in
perineal area

- 6 measured
in pain scale


Sleep
deprivation
related to
prolonged
discomfort as
manifested by
pain in
perineal area
After effective
nursing
intervention
the client will
increased her
hours of sleep

Objectives:
After 30 to 1
day of
effective
nursing
intervention
the client will:

-Gain
knowledge
about the
importance of
adequate bed
rest and its
benefits

-increase
sleeping hours


Understand
the
importance of
adequate
bedrest


> Established
rapport

> Perform Vital
signs

>Observed and
performed
physical
assessment

>Health
teaching
rendered on:
-Importance of
complete bed
rest and its
benefits

-Ways and
methods to
better sleeping
habits and
increase
comfort

-Advise client to
drink milk


>Provides
baseline data
of the client








>to help to
understand
the
importance of
complete
bedrest









> helps to
promote
relaxation


After 30 to 1
hour of
effective
nursing
intervention
the client was
able to:

-Verbalized the
importance of
complete
bedrest



-do the ways
to better
sleeping habits















Goal was
Partially Met

Problem #1
Cues/Data Nursing
Diagnosis
Planning Intervention Rationale

Evaluation
Subjective
Data:

pili lang ang
kinakain kong
gulay. isda at
karne malimit
kong kainin

wala akong
ganang kumain
dahil siguro sa
operation na
ginawa sakin


Objective Data:


-Pale skin


-skinny
appearance


-Clients food
intake are
lower in
vegetables
Imbalance
nutrition less
than body
requirements
related to lack
of interest in
food as
manifested by
clients food
intake
Goals:
After effective
nursing
intervention
the client will
increased his
food intake in
vegetables


Objectives:
After 30 to 1
hour of
effective
nursing
intervention
the client will:

>Gain
knowledge
about the
importance of
eating
different kinds
vegetables by
answering 3
out of 3
questions

>Increase
vegetable
intake

>Understand
the
importance of
eating
different kinds
of vegetables
and its benefits
By answering 2
out of 3
questions


>established
rapport


> Performed
vital signs


> Observed
and Performed
physical
assessment

>Health
teaching
regarding in:

-Importance of
eating
vegetables and
its nutrients
content

-Advise clients
to take
vitamins


-Avoid eating
junkfoods




>to gather
baseline data
of the client










> To help to
understand the
importance of
vegetables and
its nutrients in
body




> To help her
boost her
nutrients in
her body

>Junk foods
have empty
calories that
provides no
nutritional
help to the
client
caffeinated
beverages
decreased
appetit

After the
intervention
the GOAL WAS
MET

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