ASSESSMENT NURSING PLANING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Fatigue related to Short Term: Independent: After 2 hours of

decrease muscular After 2 hours of intervention the
“madalas po intervention the  Provide comfort  To maximize patient was able to:
strength
nanghihina ako.” patient will be able measures oxygenation for  Identify
As verbalized by to: cellular uptake. measures to
the patient.  Identify conserve and
measures to  Promote overall  Promotes gradual increase body
conserve health measures return to normal energy
Objective:
and increase activity level and 
 Restlessness body energy improved the Long Term Goal:
 Generalized body without After 2 days of
weakness Long Term Goal: undue fatigue intervention the
 Decreased After 2 days of patient was able to:
Performance intervention the  Monitor VS  Indicates  Improved his
patient will be able physiological level of activity
Vital Signs: to: levels of
T: 36.3 oC  Improved tolerance.
RR: 22 bpm his level of
activity  Assess muscle
PR: 85 bpm  To determine the
BP: 110/80 strength of patient
level of the
and functional level
activity
of activity
 ASSESSMENT NURSING PLANING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

Subjective: Deficient fluid Short Term: Independent: Short Term:

volume related to After 2 hours of After 2 hours of
“nagsuka po ako, intervention the  Establish rapport  To gain trust and intervention the
vomiting and
dalawang araw patient will be able cooperation patient was able to:
inadequate fluid 
na.” As verbalized to: Monitor IV  To have a  Decrease risk
intake
by the patient.  Decrease risk baseline data for
for  Evaluate nutritional  This can complications
Objective: complications status, noting negatively effect of fluid volue
of fluid volue current intake & fluid intake deficit
 Vomiting deficit problems
 Dry mucous  Monitor I & O  To insure Long Term Goal:
membrane Long Term Goal: balance accurate picture After 2 days of
 Chapped lips After 2 days of of fluid status intervention the
 Poo skin intervention the  Weight client &  To determine patient was able to:
turgor patient will be able compare trends  Moist mucous
 Intake – 800 to:  Render health  For the proper membrane and
 Voided – 10x  Moist teaching regarding understanding of good skin
 Defecated – mucous the importance of the treatment or turgor
1x membrane hydration procedure
and good skin treatment
turgor