ASSESSMENT NURSING

DIAGNOSIS
SCIENTIFIC
RATIONALE
OBJECTIVES NURSING
INTERVENTION
RATONALE EVALUATION
Subjective Data:
hindi ako
umiinom masyado
ng tubig kasi
nasusuka ako. As
stated by the
patient.

Objective Data:
Initial vital signs as
follows:
P: 79
BP: 150/80mmHg
-Weight:
-vomited 2 times/
shift
-dry skin and lips
-poor skin turgor
-insufficient oral
fluid intake

24 hours I and O:
-INPUT= 970-
1000 cc
-OUTPUT= 890cc








Deficient Fluid
Volume related
to loss of fluid
secondary to
Upper
Gastrointestinal
Bleeding






















Peptic ulcer

Exposing and
Weakening of
arterial wall


Ruptured arterial
wall


UPPER
GASTROINTE
STINAL
BLEEDING


Hematemesis


Prolonged
bleeding


Deficient Fluid
Volume






After 4 hours of
nursing
intervention with
the help of
medical
management ,
the patients
fluid volume
deficit will be
corrected as
evidenced by
slightly moist
skin and lips,
increased fluid
intake from
970mL to
1500mL/day and
as verbalized by
dinagdagan ko
na ang iniinom
kong tubig.












Independent
Reassessed patients
condition.
Reassessing patients
condition serves as
baseline data for further
effective nursing
intervention.
After 4 hours of
nursing intervention
with the help of
medical management,
goal was met as
evidenced by slightly
moist skin and lips,
fluid intake of 1500
mL/day and
verbalization of mas
dinamihan ko na ang
iniinom kong tubig.





















Vital signs taken and
recorded, noting blood
pressure.

Vital sign changes such
as increased heart rate,
decreased blood
pressure, and increased
temperature indicate
hypovolemia.
Assist patient to semi-
Fowlers position
Lessen stimulation of
the cardiac sphincter
Forced fluids to at least 1
to 2L/day .
For fluid replacement
and proper hydration
Strictly monitored Input
and Output every shift
It helps in maintaining
homeostasis in the body
Assessed the likes and
dislikes; give patients
favorite drink within the
diet if not contraindicated
Patients beverage
preferences may help to
increase oral intake.

Measured weight every
day with the same kind of
clothes and time.
Weight loss of 2% -4%
indicates mild
dehydration, 5% -9%
moderate dehydration.
Dependent:
Obtained blood specimens
for analysis of altered
result as ordered.
To assess the severity of
the problem.
Monitored blood
electrolyte levels, and
laboratory results.
Urine and serum
analysis provides
information about
extracellular levels of





electrolyte
Administered IV fluid
PNSS




ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
RATIONALE
OBJECTIVES NURSING
INTERVENTION
RATONALE EVALUATION
Subjective Data:
Hindi ko
maintindihan kung
paano nangyari sa
akin at wala namang
may alam samin as
stated by the patient.

Objective Data:
-afebrile
-good muscle
strength
-conscious and
coherent

















Deficient
Knowledge
regarding
health
condition
related to
unfamiliarity
with
information
resources.





















No one in the
members of
family
understand pts
disease
condition

Absence of
cognitive
information
about nature of
disease


Deficient
knowledge















After 15 minutes
of nursing
intervention,
patients and
patients
relatives
knowledge will
increase
regarding her
condition as
evidenced by
patients ability
to show interest
in talking about
her disease,
ability to answer
4 out 5 questions
about her
condition and as
verbalized by
naiintindihan
ko na kung bakit
ako nanghihina,
nagsusuka ng
dugo, may
pananakit sa
tyan at alam ko
na ang gagawin
sa sakit ko.


Independent
Educate the client about
the disease, length of
convalescence, and
recovery expectations.
Identify self-care and
homemaker
needs/resources.
Information can
enhance coping and help
reduce anxiety and
excessive concern.
Presence of unknown
signs and symptoms
depression and the need
for various forms of
support and assistance.
After 15 minutes of
nursing intervention,
goal was met as
evidenced by
observed interest of
patient in talking
about her condition,
ability to answer 5
out of 5 questions
regarding her disease
condition and
verbalization of
naiintindihan ko na
kung bakit ako
nanghihina,
nagsusuka ng dugo,
may pananakit sa
tyan at alam ko na
ang gagawin sa sakit
ko.











Provided information in
written and verbal form.
Fatigue and depression
can affect ability to
assimilate
information/follow
medical regimen.
Stressed importance of
continuing effective deep-
breathing exercises.
For relaxation
techniques.
Emphasized necessity for
continuing medications
for prescribed period.
Early discontinuation of
medication may result in
failure to completely
resolve health condition.
Outlined steps to enhance
general health and well-
being, e.g., balanced rest
and activity, avoidance of
eating spicy, oily foods,
caffeinated and soft
drinks.
Increases natural
defenses/immunity,
limits exposure to
pathogens.
Stressed importance of
continuing medical
follow-up after discharge.
May prevent recurrence
of pneumonia and/or
related complications.


Emphasized importance
of nutritious food and
increase fluid intake.
Nutritious foods help his
body to recover faster
and increase fluid intake
can aid his dehydration.


I. PROBLEM LIST

List of Nursing Problems Nursing Diagnosis

Prioritization of the problem is base on Maslows Hierarchy of Needs and using Airway, Breathing and Circulation Method