ASSESSMENT NURSING SCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSIS OUTCOME
S=” Masakit ku atsan” Acute Pain Lots of medicine has the side effect of gastric Short Term Objective: Establish rapport To gain pt’s Short Term
The patient manifested upset causing abdominal pain to patient after After 2 hr of nursing intervention therapeutic Objective:
the following: intake of medication specially PO drugs. It has the pt will verbalized rlieve of Monitor v/s relationship After the nsg int
O= with facial a side effect of causing abdominal cramps, and pain from 8/10 to 4/10 the pt shall
grimace, with guarding pain. Assess pt’s general To obtain baseline verbalized a
behaviors, pain scale Long Term Objective: condition data relief of pain.
of 8/10, at abdominal After 3 days of NI, pt will
area, with quality of demonstrate technique to alleviate Encourage rest To note for the Long Term
dull pain, after intake pain opportunities etiology or Objective:
of meds, left side precipitating After the nsg int
paralysis Ecourage diversional factors that can the pt shall
The patient may also activities such as talking to lead to fever. demonstratetech
manifest he following: S.O. nique to
>discomfort>anxiety>i To overcome pain alleviate pain
rritable>Fatigue>heada Encourage deep breathing at restto divert the
che exercises pt’s attention

Provide comfort measures Helps to lessen the

and safety feeling of pain.

Provide Health information To let pt feel safe

regarding the occurring
problem
Provide conducive
environment for resting
and comfortable
To lessen the pt’s
feeling of anxiety
To promote rest
and pt’s wellness

ASSESSMENT NURSING SCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSIS OUTCOME
S= 0 Impaired In cerebral tissue perfusion, there is a decrease Short term objective: Establish Rapport > To gain pt’s Short term
The patient manifested cerebral tissue in oxygen supply which results in the failure After 5hrs. of Nursing therapeutic objective:
the ff: perfusion r/t to nourish the tissues at the capillary level. intervention, the pt. will Monitor Vital signs relationship After 5hrs. of
O= without signs of IV vascular Blood vessels which function is to supply demonstrate increased perfusion Nursing
infiltration, w/ occlusion blood to the different parts of the brain are as individually appropriate Assist pt. in assuming > To identify any intervention, the
contralateral secondary to impaired. Thus, the O2 supply going to the Long Term Objective: semifowler’s position w/ other deviations pt. shall be able
hemiparesis, sensory disease brain is also impaired. Proper perfusion is After 2-3 days of Nursing head midline. from normal. to demonstrate
loss, muscle weakness, condition needed in order to give adequate nourishment Intervention, the pt. will be able o increased
slurred speech, with to he different parts of the brain in order for it demonstrate behaviors which may Administer medications as >To aid with perfusion as
GCS=15 to function well improve proper circulation such ordered such as proper perfusion individually
as compliance to health antihypertensive or or flow of blood appropriate
The patient may also management & therapies diuretics. (circulation or
manifest the ff: provided. venous drainage). Long Term
>Change in pupillary >Encourage quiet and Objective:
reactions restful atmosphere. >To probably After 2-3 days
>Change in Mental decrease cardiac of Nursing
Status >Exercise caution in using workload and in Intervention, the
>Behavioral Changes hot or cold pads. maximizing tissue pt. shall be able
>Capillary refill longer perfusion to demonstrate
than 3 secs. >Encourage use of behaviors which
 relaxation techniques or >To conserve may improve
exercises. energy which proper
could aid in circulation such
>Discuss the importance of lowering the O2 as compliance to
preventing exposure to cold tissue demand. health
or extreme cold temp management &
>The t issues may therapies
>Discuss to the patient’s have decreased provided.
SO the importance of care sensitivity due to
of dependent limbs, body ischemia.
hygiene, and foot care when
circulation is impaired. >To decrease the
tension level

>To retain heat or

warmth efficiently

>To promote
wellness

ASSESSMENT NURSING SCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSIS OUTCOME
S= 0 Impaired The nervous system is made up of nerve cells Short Term Objective: >Establish Rapport > To gain pt’s Short Term
The patient manifested physical called neurons that serve as the After 4 hrs. Of Nursing therapeutic Objective:
the following: mobility communication system of the body. They Intervention, the pt. will be able >Monitor Vital signs relationship After 4 hrs. Of
O= w/ pale palpebral neuromuscular carry messages in the form of electrical to maintain increased strength and Nursing
conjunctiva, w/ pale and impulses. The messages move from one function of affected or >Assess patient condition > To identify any Intervention, the
nail beds, w/ capillary musculoskeletal neuron to another to keep the body compensatory part. other deviations pt. shall be able
refill time, <3sec. pt. is impairment as functioning. Because neurons have, limited >Provide adequate rest from normal. to maintain
able to feel deep touch, evidence by ability to repair themselves unlike other body Long Term Objective: periods as well as comfort increased
raise his right arm and limited motor tissues that is why nerve cells cannot be After 2-3 days of nursing & safety measures >Todetermine any strength and
leg, w/ slurred speech, skills repaired if damaged due to injury or disease. intervention, the pt. will be able to other underlying function of
w/ left sided weakness, demonstrate behaviors that enable >Turn pt. slowly from side cause of affected or
with limited ROM on resumption of activities. to side manifestations> compensatory
upper and lower part.
extremities, afebrile, >Determine pt. level of To prevent further
(-) DOB, (-) chest pain. mobility stress & fatigue Long Term
Objective:
The patient may also >Assist pt. in his activities > To provide After 2-3 days
manifest he following: proper circulation of nursing
>Slowed >Encourage adequate intake of blood flow on intervention, the
movement,>Postural of fluids & Nutritious foods both sides pt. shall be able
instability during to demonstrate
performance of >Involve client’s SO in care >To assess behaviors that
ADLs>Movement functional ability enable
induced shortness of resumption of
breath. >To promote activities.
optimal level
offunction

>Promotes well-
being and
maximizes energy
 production.

>To assist in
learning ways of
managing
problems of
immobility.

ASSESSMENT NURSING SCIENTIFIC EXPLANATION PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSIS OUTCOME
S= 0 impaired verbal There is an affectation of the certain brain Short Term Objective: Establish rapport To gain pt’s Short Term
The patient manifested and/or written lobes that caused by impaired cerebral After 3 hrs of nsg int. the pt will therapeutic Objective:
the following: communication circulation that affects its proper functions that be able to verbalize or indicate Monitor v/sAssess pt’s relationship After the nrsing
O= w/ pale palpebral r/t impaired leads to decreased, delayed or absent ability to understanding of the general condition intervention the
conjunctiva, w/ pale cerebral receive, process, transmit and use a system o communication difficulty and To obtain baseline pt shall
nail beds, w/ capillary circulation symbols in communicating resulting in plans for ways of handling. Note results of neurological data verbalize ir
refill time, <3sec., pt. impaired verbal communication Long Term Objective: testing such as EEG/CTscan indicate
is able to feel deep After 3 days of nursing and the likes To note for the understanding of
touch, raise his right intervention the pt will establish etiology or communication
arm and leg, w/ slurred method of communication in Assess environment factors precipitating difficulty and
speech, w/ left sided which needs can be expressed. that may affect ability to factors that can plans for ways
weakness, with limited communicate lead to fever. of handling
ROM on upper and
lower extremities Establish relationship with To assess Long Term
the client , listening causative/contribu Objective:
The patient may also carefully and attending to ting factors After the
manifest he following: clients verbal/nonverbal nursing
>weakness>headache> expressions To assess intervention the
dyspnea>unable to causative/contribu pt shall be albe
speak>discomfort>irrit Maintain a calm, unhurried ting factors to establish
ability>low self manner, provide sufficient methods of
esteem>Difficulty in time for the client to To assist client to communication
expressing needs responds establish a means in which can be
of communication expressed.
Anticipate needs until to express needs,
effective communication is wants, ideas and
reestablished questions
Administer due meds Individuals may
talk more easily
when they are
rested and relaxed

To attend pt’s
needs immediately

For pt’s recovery

and to treat
underlying
conditions