Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

A Subjective: Short term goal: IMPLEMENTATION RATIONALE  After 8 hours of
Infection
 “Walang gana related to  After 8 hours of INDEPENDENT: nursing
dumede si baby nursing 1. Provide Isolation and interventions, the
compromised
(name), medyo interventions, the monitor visitors as  Body substance patient was able
mainit siya at immune patient will indicated isolation (BSI)
system as to achieve timely
matamlay” achieve timely should be used
C (It’s difficult to evidenced by healing and free
healing and free
for all infectious from further
feed my baby, elevated WBC from further patients.
she feels warm infection infection
levels (20.5) Reverse
to touch and not isolation/restricti
very active) as on of visitors
verbalized by may be needed to
T the mother protect the
immunosuppress
Objective ed patient.
T: 38.0 C
P: 141  Reduces risk of
R: 56 2. Wash hands before or cross
U WBC: 20.5 after each care activity, contamination
even gloves are used. because gloves
may have
noticeable
defects, get torn
A or damaged
during use

 Prevents spread
3. Limit use of invasive of infection via
devices or procedure as airborne
possible droplets.
L
4. Inspect wounds or site of  May provide

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Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES
www.perpetualdalta.edu.ph • +63(02) 871-06-39

invasive devices, paying clue to portal

particular attention to entry, type of
parenteral lines. primary infecting
organisms, as
well as early
identification
secondary
infection.

 Prevents
5. Maintain sterile technique introduction of
when changing dressings, bacteria,
suctioning or providing site reducing risk of
care. nosocomial
infection.

6. Provide tepid sponge bath  Used to reduce

and avoid use of alcohol. fever

7. Observe for chills and  Chills often

profuse diaphoresis precede
temperature
spikes in
presence of
generalized
infection.

8. Monitor for signs of  May reflect

deterioration of condition or inappropriate
failure to improve in antibiotic therapy
therapy. or overgrowth of
secondary
infections.
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 Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES
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COLLABORATIVE:

1. Obtain specimens  Identification of

of urine, blood, portal entry and
sputum, wound as organism causing
indicated for gram the septicemia is
stain, and crucial in
sensitivity. effective
treatment.

2. Administer antibiotics as  To prevent

prescribed further spread of
infection

A ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Objective: Ineffective Short term goal: IMPLEMENTATION RATIONALE Short term goal:
 Patient is attached airway After 1-2 hours of INDEPENDENT: Goal met, After 1-
to mechanical
clearance nursing 1. Assessed airway for  Maintaining patent 2 hours of nursing
ventilator and ET intervention, the patency. airway is always the intervention, the
size 7.5, level 19 related to patient will be able first priority, especially patient was able
C Fi02= 60% stasis of to: to:
in cases like trauma,
tV= 360 secretion  Show patent acute neurological  Show patent
BUR= 16 airway and less decompensation or airway and less
secretions cardiac arrest. secretions.
 Presence of 2. Assessed respirations.
T
abnormal breath Long term goal: Note quality, rate, depth,  A change in the usual Long term goal:
sounds After 3 days of flaring of nostrils, respiration means Goal partially
providing the dyspnea on exertion, use respiratory met, After 3 days
 Crackles during nursing of accessory muscles. compromise. An of providing the
inspiration and intervention, the increase in respiratory nursing
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 Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES
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wheezes during patient will: rhythm may be a intervention, the

expiration  Maintain clear, 3. Noted for changes in compensatory response patient was able
patent airways as mental status. to airway obstruction. to:
 Patient is evidenced by  Maintain clear,
unconscious with normal breath  Increasing lethargy, patent airways
GCS of 3/15 sounds, normal confusion, restlessness as evidenced by
(E1V1M1) rate and depth of and for irritability can normal breath
respirations and be initial signs of sounds, normal
ability to cough 4. Noted for changes in HR, cerebral hypoxia. rate and depth
 Yellowish with up secretions BP, and temperature. Lethargy and of respirations
some presence after treatments somnolence are late but patient has
blood secretions and deep breaths signs. inability to
 Classify methods cough up
to enhance  Increased work of secretions after
secretion breathing can lead to treatments and
removal tachycardia and deep breaths.
 Identify and hypertension. Retained
avoid specific 5. Assessed pressure of secretions or atelectasis
factors that sputum. Evaluate it may be a sign of an
inhibit effective quality, color, amount, infection or
airway clearance odor & consistency. inflammatory process
manifested by a fever
or increased
temperature.

6. Assessed hydration status:  Unusual appearance of

skin turgor, mucous
membranes, tongue.
7. Positioned the patient
upright if tolerated
regularly. Check the
patient’s condition to
secretions may be a
result of infection.
Dehydration may be
present if patient has
labored breathing with
thick, tenacious
secretions that increase
airway resistance.

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 Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES
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prevent sliding down in

bed.  Airway clearance is
impaired with poor
hydration and
8. Performed endotracheal subsequent secretion
suctioning thickening.

 Upright position limits

9. Provided oral care every 4
hours.
COLLABORATIVE:
1. Referred to the
pulmonary critical nurse
specialist or respiratory
therapist.
 Suctioning is need for
abdominal contents
from pushing upward
and inhibiting lung
expansion. This
position promotes
better lung expansion
and improve air
exchange.
patients who are unable
to cough out secretions
properly due to
weakness, thick mucus
production.

 Oral care freshens the

mouth after respiratory
secretions has been
expectorated.
 Consultants may be
helpful in ensuring that
treatment are met.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

A
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 Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES
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Objective: Deficient Short term goal IMPLEMENTATION RATIONALE Short term goal
 Patient is Fluid volume After 8 hours of INDEPENDENT: Goal not met,
unconscious with nursing After 8 hours of
related to
GCS of 3/15 intervention 1. Monitor and  Decrease in circulating nursing
(E1V1M1) subarachnoid Client will be able document vital signs blood volume can cause intervention
hemorrhage. to maintain fluid especially BP and HR. hypotension and Client wasn’t
 Dry lips and volume at a tachycardia. Alteration able to maintain
mucus functional level as in ** is a compensatory fluid volume at a
membranes evidence by stable mechanism to maintain functional level as
vital signs, moist cardiac output. Usually, evidence by
 Edema on both mucous the pulse is weak and unstable vital
arms membranes and may be irregular if signs, dry mucous
adequate urine electrolyte imbalance membranes and
 Hypotension (BP output also occurs. Hypotension inadequate urine
of 60/30 mmHg) 2. Asses skin turgor and is evident in output.
Long term goal: oral mucus membranes hypovolemia.
 Bradycardia (PR After 3-5 days of for signs of dehydration. Long term goal:
of 46 bpm) nursing  Signs of dehydration are Goal not met,
intervention, the also detected through After 3-5 days of
 Urine output of patient will be able 3. Assess color and skin. Longitudinal nursing
less than 20 cc/hr to: amount of urine output. bumps may be noted intervention, the
 Be normovolemic Report urine output less along the tongue. patient was not
as evidenced by than 30 ml/hr. able to:
 Creatinine level: systolic greater  A normal urine output is  Be
115.37 umol/L than or equal to 4. Administer parenteral considered normal not normovolemic
90 mmHg, fluids as prescribed. less 30 ml/hr. as evidenced by
absence of Consider the need for an Concentrated urine systolic greater
 Chloride level: orthostasis, HR of IV fluid challenge with denotes fluid deficit. than or equal to
131.00 mmol/L 60-100 bpm, immediate infusion of 90 mmHg,
urine output of fluids.  Fluids are necessary to absence of
 Sodium level: 30ml/hr and maintain hydration status orthostasis, HR
163.00 mmol/L normal skin Determination of the of 60-100 bpm,
turgor 5. Provide comfortable type and amount of the urine output of
 Demonstrate environment by fluid to be replace and 30ml/hr and

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 Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES
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lifestyle changes covering patient with infusion rate will vary normal skin
to avoid light sheets or light depending on clinical turgor
progression of clothing. status. Demonstrate
dehydration lifestyle changes
 Drop situations where to avoid
patient can experience progression of
overheating to prevent dehydration
further fluid loss.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

P
Objective: Risk for Short term goal: IMPLEMENTATION RATIONALE
42

O
 Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES
www.perpetualdalta.edu.ph • +63(02) 871-06-39

 Patient is Impaired Skin After 8 hours of 1. Determine age.  Elderly patient’s skin is
unconscious with nursing normally less elastic and
Integrity has less moisture, making
GCS of 3/15 intervention, the
(E1V1M1)
related to patient will have for higher risk of skin
Neuromuscular her skin intact as impairment.
2. Evaluate patient’s
 Patient is Function evidenced by consciousness of the  Patient with diminished
attached to secondary to absence of sensation of pressure. sensation are unconscious
mechanical Immobility bedsores in any of unpleasant stimuli and
ventilator and ET part of the do not shift load. This
size 7.5, level 19 extremities. result in protracted
Fi02= 60% pressure on skin capillaries
tV= 360 3. Watch fluid intake and and in the end, skin
BUR= 16 hydration or skin and ischemia.
mucus membranes.
 No response  Monitor incidence of
dehydration or over
to any stimuli. 4. Boost tissue perfusion by hydration that affect
offering gentle massage circulation and tissue
around reddened or integrity at the cellular
blanched areas. level.

5. Clean, dry and moisturize  Enhances blood flow,

skin particularly over bony reducing tissue hypoxia.
prominences, twice daily
or as necessary.

6. Maintain linen dry and  Keep cleanliness without

free of wrinkles, crumbs. irritating the skin.
7. Turn patient every 2 hours.

 Moisture exacerbates
pruritus and augments risk
of skin breakdown.

 Improves circulation and

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 Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES
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avoid unnecessary
pressure on skin or tissues.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

P
Subjective; Anticipatory Short term goal: IMPLEMENTATION RATIONALE
 “Nangangamba After 30 minutes INDEPENDENT:  Although the grieve is
at nalulungkot Grieving to 1 hour of 1. Assess stage of anticipatory, the significant
O akong isipin na nursing grieving being others may move from stage to
mawawala related to intervention, the experienced by the stage again before acceptance
siya” as family will be able significant others: occurs. This will help teaching
perceived denial, anger, the people about the process of
verbalized by to express grief
bargaining, depression grief.
T the significant and participate in and acceptance.
others potential loss the decision
making in the 2. Identify potential for  Anticipatory grief is helpful in
of loved one future. pathological grieving preparing individual to do
E Objective: response. actual grief work. Those who
 The patient’s do not grieve in anticipation
physician held maybe at higher risk for
a family dysfunctional grief.
N conference
discussing the
3. Observe non-verbal  Body language may
communication. communicate a great deal of
poor prognosis
information especially if the
T of the patient. family are unable to vocalized
their concerns.

4. Minimize  Provide mourners with a quiet,

I environmental stresses private environment with no
or stimuli. interruptions.

5. Provide realistic  Defensive retreat can occur

A information about weeks to months after the loss.
health status without The family attempts to
false assurance or maintain what has been loss.
taking away hope.
L
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Alabang-Zapote Road, Pamplona 3, Las Piñas City, Metro Manila 1740, PHILIPPINES
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