ASSESSMENT NURSING SCIENTIFIC PLANNING IMPLEMENTATION SCIENTIFIC RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Acute pain Mechanical, Short Term Independent: Promotes Outcome Achieved.
“Masakit yung tiyan related to thermal or Outcome: Encourage cooperation Client stated 3 ways
ko lalo na kapag gastrointestinal chemical stimuli. After 3 hours of patient to from the client. of relieving pain such
kumakain” as irritation nursing verbalize (Fundamentals as imagery,
verbalized by the secondary to interventions: about pain. of Nursing by application of hot
client. dengue Nociceptors 1. the client Taylor 5th e. and cold compress
hemorrhagic will state 3 Provide p.1216) and therapeutic
fever.
Afferent Nerves
ways of comfort This calms and touch.
Objective: relieving measures such soothes the
>Facial grimace pain such as as deep patient.
when palpating the imagery, breathing (Fundamentals
abdominal area. End terminals application exercises like of Nursing by
>Guarding behavior of hot and yoga and Taylor 5th e.
on the abdominal cold meditation. p.1216)
area. unmyelinated C compress Encourage
>Pain scale of 5 out fibers and and diversional To divert
of 10. myelinated-A delta therapeutic activities attention from
fibers touch. (TV/radio, pain.
2. the client’s socialization (Fundamentals
pain scale with others, of Nursing by
will decrease imagery) Taylor 5th e.
spinal cord from 5/10 to Provide p.1216)
3/10. application of
brain cortex hot and cold To relieve pain
compress. in the muscle
area. Maternal
and Child Health
Pain Provide Nursing 5th e. by
therapeutic Pilliteri page
touch. 547)
To promote
feeling of
REFERENCE: comfort.
Maternal and Child (Maternal and
Health Nursing 5th e. Child Health
by Pilliteri page 545 Nursing 5th e. by
Pilliteri page
547)
An information
baseline
comparison
from previous
Monitor Vital data. (Manual of
signs. Nursing
Procedures Vol. I
by Locquiao,
Cruz, Arguelles
and Lontoc page
122)
To comply with
the physician’s
Collaborative: order. (Manual
Administer of Nursing
Mefenamic Procedures Vol.
Acid and II Locquiao,
Toradol Manalastas,
(analgesic) as Mejilla and
ordered. Merin. page 3)
Assessment Diagnosis Planning Intervention Rationale Evaluation
Objective Data -Hyperthermia related to Short – Term Goal Independent
Pale and weak disease process as -After 30 mins. of
in appearance evidenced by weak and -After 30 mins. of -v/s taking -To establish a data continuous T.S.B client’s
Dry mucous pale appearance Nsg. Intervention base. temp. subsides to 37.4 ۫C
membrane client’s temp. will
. subside to 37.5 ۫C ↓ -Tepid sponge bath -To open pores and -After 8 hours of duty
Measurable Data release excess heat pt. has better fluid
V/S Long – Term Goal in the body. volume as evidenced by
T – 38.1 -Remove excess -To promote moist mucous
-After 8 hrs. of duty blankets comfort and membrane.
pt. will maintain prevent convulsion.
fluid volume at
functional level -Increase fluid intake -To prevent further
dehydration
-Measure accurate I/O -To assess fluid
volume
- provide health
teachings to parents -To mobilize
(importance of hand secretions
washing)
-To enhance Health
awareness
