ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Hyperthermia A viral infection will After thirty minutes Independent: After thirty minutes
“Bago po lumabas related to systemic induce systemic of nursing care, the -Assess vital signs -this will provide the of nursing care, the
mg rashes na to viral infection inflammation that client’s body specifically body nurse baseline data client’s body
hanggang ngayon will induce fever. temperature will be temperature temperature was
nilalagnat po ako” down from 38.1’C lowered down from
to 37.0’C -Instruct the client -As the body 38.1’C to 37.0’C
Objective: to facilitate oral temperature of the
-warm to touch hydration patient rises, there
-flushing comes an ongoing
-facial grimace loss of fluid via
-diaphoresis evaporation.
-T- 38.1’C Therefore, it is
necessary to replace
fluid losses

-Instruct the client -Having a thick

to have a loose amount of clothing
clothing will prevent heat
from evaporating
from the patient’s
body

-Facilitate tepid -Water from the

sponge bath sponge bath may
lower down the
patient’s core
temperature

Dependent:
-Administer -Such medications
prescribed are effective in
medications for lowering the
fever (Paracetamol patient’s body
300mg tab q4h) temperature
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Impaired skin Measles virus is The client will -Obtain history of -This will provide The client displayed
“Makati po yung integrity related to spread through display timely condition the nurse a baseline timely healing of
balat ko tapos viral skin infection body organs via the healing of the skin data about the the skin lesions
nagsusugat.” lymphatic system lesions after condition of the after multiple series
including the skin, multiple series of client of nursing
Objective: therefore, causing nursing interventions.
-Evident skin lesions rashes. interventions. -Keep the lesions -So that the patient
(erythematous clean and dry would nit have
maculopapular further
rash) contamination
-Observable
disruption of the -Promote -Diversional
skin surface diversional activities activities will divert
such as watching tv, the patient’s
listening to music, attention
chatting with SO

-Emphasize to the -This action will

client the lessen the patient’s
importance of risk to further
personal hygiene infection
and bathing

Dependent:
-administer the -These medications
prescribed are known to lessen
antivirals (acyclovir, the viral activity of
valacyclovir) the virus therefore
causing lesser
lesions

-administer -These medications

prescribed anti- inhibit release of
histamines histamine,
(cetirizine, therefore lessening
diphenhydramine, the prutitus
loratadine)
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Deficient knowledge - After proper and -Determine the -this action will help After proper and
“Di ko po alam kasi about current timely nursing patient’s level of the nurse to cope timely nursing
kung paano ko po health condition interventions, the understanding, with the client’s interventions, the
nakuha etong sakit client will: primary language, understanding by client :
na to.” (Measles) and level of using terms that are
-display readiness education familiar to him -displayed readiness
Objective: for enhanced for enhanced
-hesitance to giving learning -Discuss to the -This is to correct learning
insights about the client the virus’ the misconception
current condition -understand the mode of that measles virus is -understood the
-asks questions current condition of transmission is transmitted via current condition of
frequently the client, its airborne direct contact the client, its
-displays poor eye treatment, treatment,
contact prognosis and -Discuss to the -This action will prognosis and
prevention client the treatment enable the client to prevention
of measles, the be actively
purpose of participating in his
medications that treatment course by
are given to him knowing the
rationale of each
procedure

-Stress to the client -This action will

the importance of raise the client’s
prevention (wearing awareness and
mask, proper cough cautiousness about
etiquette, hand the disease’s
hygiene and transmission
vaccination
[measles vaccine])

-Provide health -This can help to

teachings about reduce mortality
isolation and (fetal death), and
acquiring the also the people
disease throughout affected
pregnancy
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Acute pain related A viral infection will After thirty minutes Independent: After thirty minutes
“Masakit po ulo ko to generalized induce systemic of nursing care, the -determine the -This action will of nursing care, the
at mga kasu inflammatory inflammation that client’s pain scale severity, onset, and provide the client’s pain scale
kasuan” response will induce pain will be down from location of pain healthcare was lowered down
6/10 to 3/10 or providers baseline from 6/10 to 3/10
Objective: lesser data and they will or lesser
-guarding behavior know what actions
-facial grimace are to be
-diaphoresis implemented next
-Pain scale of 6/10

-Apply cold or heat -Instead of sending

application to the the impulse of
affected area somatic pain, the
depending on the nervous system will
preference of the send the impulses
patient of the hot or cold
sensation to the
brain to lessen the
pain

-Encourage the -This will divert the

patient to do client’s attention
diversional activities from the pain he’s
such as watching tv, feeling
reading books

Dependent:
-Administer pain -Such medications
medications as are effective in
prescribed (NSAIDs) lessening or
removing pain to
the patient’s body
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Impaired skin Measles virus is The client will -Obtain history of -This will provide The client displayed
“Makati po yung integrity related to spread through display timely condition the nurse a baseline timely healing of
balat ko tapos viral skin infection body organs via the healing of the skin data about the the skin lesions
nagsusugat.” lymphatic system lesions after condition of the after multiple series
including the skin, multiple series of client of nursing
Objective: therefore, causing nursing interventions.
-Evident skin lesions rashes. interventions. -Keep the lesions -So that the patient
(erythematous clean and dry would nit have
maculopapular further
rash) contamination
-Observable
disruption of the -Promote -Diversional
skin surface diversional activities activities will divert
such as watching tv, the patient’s
listening to music, attention
chatting with SO

-Emphasize to the -This action will

client the lessen the patient’s
importance of risk to further
personal hygiene infection
and bathing

Dependent:
-administer the -These medications
prescribed antivirals are known to lessen
(acyclovir, the viral activity of
valacyclovir) the virus therefore
causing lesser
lesions

-administer -These medications

prescribed anti- inhibit release of
histamines histamine,
(cetirizine, therefore lessening
diphenhydramine, the prutitus
loratadine)
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Deficient knowledge - After proper and -Determine the -this action will help After proper and
“Di ko po alam kasi about current timely nursing patient’s level of the nurse to cope timely nursing
kung paano ko po health condition interventions, the understanding, with the client’s interventions, the
nakuha etong sakit client will: primary language, understanding by client :
na to.” (German and level of using terms that are
Measles) -display readiness education familiar to him -displayed readiness
for enhanced for enhanced
Objective: learning -Discuss to the -This is to correct learning
-hesitance to giving client the virus’ the misconception
insights about the -understand the mode of that measles virus is -understood the
current condition current condition of transmission is transmitted via current condition of
-asks questions the client, its airborne direct contact the client, its
frequently treatment, treatment,
-displays poor eye prognosis and -Discuss to the -This action will prognosis and
contact prevention client the treatment enable the client to prevention
of measles, the be actively
purpose of participating in his
medications that treatment course by
are given to him knowing the
rationale of each
procedure

-Stress to the client -This action will

the importance of raise the client’s
prevention (wearing awareness and
mask, proper cough cautiousness about
etiquette, hand the disease’s
hygiene and transmission
vaccination [Rubella
vaccine])

-Provide health -This can help to

teachings about reduce mortality
isolation and (fetal death), and
acquiring the also the people
disease throughout affected
pregnancy
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Acute pain related Blockage in the After thirty minutes Independent: After thirty minutes
“Masakit po tiyan to parasitic intestine causes of nursing care, the -determine the -This action will of nursing care, the
ko dahil sa bulate, infestation and enlargement of the client’s pain scale severity, onset, and provide the client’s pain scale
naharangan na daw blockage of the intestine triggering will be down from location of pain healthcare was lowered down
po yung bituka ko” intestine. the pain receptors 9/10 to 5/10 or providers baseline from 9/10 to 5/10
in the peritoneal lesser data and they will or lesser
Objective: cavity. know what actions
-guarding behavior are to be
-facial grimace implemented next
-diaphoresis
-Pain scale of 9/10
-Apply cold or heat -Instead of sending
application to the the impulse of
affected area somatic pain, the
depending on the nervous system will
preference of the send the impulses
patient of the hot or cold
sensation to the
brain to lessen the
pain

-Encourage the -This will divert the

patient to do client’s attention
diversional activities from the pain he’s
such as watching tv, feeling
reading books

Dependent:
-Administer pain -Such medications
medications as are effective in
prescribed (NSAIDs) lessening or
removing pain to
the patient’s body
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Anxiety related to Patients with The patient will -Establish -This action is taken The client displayed
“Baka po mamatay perceived threat of ongoing disease state that he has no therapeutic rapport to have an open and timely healing of
ako dahil sa mga death process, especially thoughts about trusting relationship the skin lesions
bulate ko. surgical cases often anxiety, or dying with the patient. after multiple series
Ooperahan po kasi have thoughts after timely and of nursing
ako, tatanggalin” about dying and therapeutic nursing -Explore the -This will help the interventions.
having fear of the care. patient’s feelings nurse to determine
Objective: unknown. These and thoughts the extent, and
-irritability factors cause factors that causes
-poor eye contact anxiety. thepatient’s anxiety.
-voice quivering
-trembling -Be therapeutic -Communicating
-v/s: when therapeutically will
BP- 140/100 communicating with help te client
T- 36.5’C the patient alleviate fear and
P-126 anxiety. Also, it
R-27 might lessen the
threat perceived by
the client to a
health professional

-Encourage -Diversional
diversional activities activities will divert
the client’s
attention to relieve
anxiety

-Encourage familial -The patient’s family

involvement in the is a big influence to
treatment course himself

Dependent:
-Administer -These medications
prescribed are effective for the
anxiolytics evident physiologic
(midazolam, response of the
diazepam) patient
ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: Deficient knowledge - After proper and -Determine the -this action will help After proper and
“Paano po ba about current timely nursing patient’s level of the nurse to cope timely nursing
maiiwasan itong health condition interventions, the understanding, with the client’s interventions, the
sakit na client will: primary language, understanding by client :
ito?(Ascariasis) and level of using terms that are
-display readiness education familiar to him -displayed readiness
Objective: for enhanced for enhanced
-hesitance to giving learning -Discuss to the -This is to correct learning
insights about the client that the the misconception
current condition -understand the parasite’s mode of that measles virus is -understood the
-asks questions current condition of transmission is transmitted via current condition of
frequently the client, its fecal-oral direct contact the client, its
-displays poor eye treatment, treatment,
contact prognosis and -Discuss to the -This action will prognosis and
prevention client the treatment enable the client to prevention
of ascariasis, the be actively
purpose of participating in his
medications that treatment course by
are given to him knowing the
rationale of each
procedure

-Stress to the client -This action will

the importance of raise the client’s
prevention awareness and
(deworming by cautiousness about
mebendazole if the disease’s
there is suspected transmission
parasitic infection,
hand hygiene,
proper food
preparation)