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Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Sleep deprivation After 2 hours of nursing -provide cold compress -to promote constriction After 2 hours of nursing
related to pain intervention, the client to the site. of the vein and relief to intervention the client
“iyak sya ng iyak secondary to removal of sleep pattern will return the site sleep pattern had return
pagkatapos tanggalin the intravenous fluid to normal. -provide a silent to normal. Goal met.
nung nasa kamay line. environment that is -to promote comfort
nya,hindi tuloy siya comfortable for the
makatulog“, as patient
verbalized by the -the baby has its own
mother. -teach parents to
comfort the baby after way to comfort and calm
Objective: 5-10 minutes of crying herself

-loud lust cry

-facial grimace


-bleeding in the IV
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: “nilalagnat Hyperthermia related to After 30 minutes of -monitor temperature, -to acquire base line After 30 minutes of
siya dahilsa inpeksyon infection. nursing intervention, the heart rate, and rhythm data nursing intervention, the
nya” as verbalized by patient core patient core
the mother. temperature will - administer medication - to decrease temperature had
decrease within normal given by the physician temperature by means decreased within normal
Objective: range. of medication range.
- promote surface
-T: 38.7 °C cooling by means of -to decrease
tepid sponge bath temperature through
-flushed skin, warm to evaporation and
touch, red cheecks conduction
-loud lust cry, irritability