Excess Fluid Volume – Increased Isotonic Fluid RetentionAssessment Diagnosis Planning Intervention Rationale EvaluationS> “nahihirapan akong huminga” as verbalized by the patient

O> EdemaIntake exceeds output.Adventitious breath soundsS3 heart sound Pulmonary congestion Change in mental status

Excess fluid volume n/t excess sodium intake AMB edema, intake excess outputs, adventitious breath sounds, S3 heart sound, pulmonary congestion, change in mental status

W/in 2-30 of nursing intervention the client will be able to:

Stabilized fluid volume as evidenced by balance I/O, vital signs with in clients normal limits, stable weight, and free of signs of edema.

Verbalize understanding of individual dietary/fluid restrictions.

Demonstrate behavior to monitor fluid status and reduce recurrence of fluid excess.

Note presence of medical conditions/situations that potentate fluid excess.

Note amount /rate of fluid intake from all sources: PO, IV, ventilator and so forth.

Review intake of sodium and protein

Osculate breath sounds

Evaluate mentation

Elevate edematous extremities change position frequently

Measure abdominal girth.

Nursing Priority #2

Nursing Priority #1

Nursing priority #2

For presence of crackles /congestion

For confusion, personality change.

To reduce tissue presence and risk of skin breakdown

For changes that may

Was the client able to Stabilize fluid volume as evidenced by balanced I/O vital signs, within clients normal limits, stable weight and free of sign of edema.Verbalized understanding of individual dietary/fluid restrictions. Demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess.Yes ___ No ____Goals met ____Partially met ____Not met ____

indicate increasing fluid retention/edema

Ineffective Infant Feeding Pattern – Impaired ability of an Infant to suck or coordinate the suck/swallow responseAssessment Diagnosis Planning Intervention Rationale EvaluationS> “Hindi po dumedede ang aking baby” as verbalized by the mother.

O> Inability to initiate/sustain an effective suck>Inability to coordinate sucking, swallowing, and breathing.

Ineffective Infant feeding pattern r/t prematurity and oral hypersensitivity AMB, inability to initiate/sustain an effective suck, Inability to coordinate sucking, swallowing, and breathing.

W/in 12O of nursing intervention the client will be able to:

Display adequate output as measured by sufficient number of wet diapers daily.

Demonstrate appropriate weight gain.

Be free of aspiration.

Assess infant’s suck, swallow and gag reflexe’s

Determine level of consciousness, neurological impairment, seizure activity, presence of pain

Compare birth and correct weight/length measurements.

Assess sign of stress when feeding.

Determine appropriate method for feeding (e.g. special nipple/feeding device, gavage/enteral tube feeding) and choice of breast milk/formula to

Provides comparative

Nursing priority #1

Nursing priority #1

Nursing priority #1

Nursing priority #2

Was the client able to:Display adequate output as measured by sufficient number of wet diapers.Demonstrate appropriate weight gain.Be free from aspiration

Yes ___ No ____Goals met ____Partially met ____Not met ____

meet infants needs

Limit duration of feeding to maximum of 30 minutes based on infant’s response (e.g. signs of fatigue)

Refer mother to lactation specialist for assistance and support in dealing of unsolved issues.

To balance energy expenditure with nutrient intake.

Nursing priority #2

Risk for Impaired Liver Function – At risk for liver dysfunctionAssessment Diagnosis Planning Intervention Rationale EvaluationS>

O>

Risk for Impaired Liver dysfunction r/t unknown etiology

W/in 2-3O of nursing intervention the client will be able to:

Demonstrate behaviors lifestyle changes to reduce risk factors and protect self from injury.

Be free of signs of liver failure as evidenced by liver function studies w/in normal levels and absence of jaundice hepatic enlargement or altered mental status.

Assess for exposure to contaminated food or poor sanitation practices by food service workers

Educate client on way(s) to prevent exposure.

Assist with medical treatment of underlying condition

Encourage the client with liver dysfunction to avoid fatty foods, fat interferes with normal function of livercells and can cause additional

Poses risk for exposure to entric viruses (hepatitis A and B)

To reduced incidenced of HBV and HCB infections/limit damage liver

To support organ function and minimize liver damage

Nursing priority #2

Was the patient able to:

Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Free of signs of liver failure as evidenced by liver function studies with in normal levels and absence of jaundice hepatic enlargement or altered mental status.

Yes ___ No ____Goals met ____Partially met ____Not met ____

damage/permanent scarring to livercells when they can no longer regenerate.

Risk for Constipation – At risk for decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or excessively large, dry stool.

Assessment Diagnosis Planning Intervention Rationale EvaluationS>

O>

Risk for constipation r/t unknown etiology

W/in 2-5Oof the client will be able to:

Maintain usual pattern of bowel functioning

Demonstrate behaviors or lifestyle changes to prevent developing problem.

Discuss usual elimination pattern and use of laxatives.

Evaluate current dietary fluid intake and implications for effect on bowel function

Promote adequate fluid intake, including water and high – fiber fruit juices, also suggest drinking warm fluids

Encourage activity exercises with in limits of individual ability

Discuss Physiology and acceptable variations in elimination

Encourage

Nursing Priority #1

Nursing Priority #1

Promote soft stool and stimulate bowel activity

To stimulates contractions of the intestines

May help reduce concerns/anxiety about situation.

To help monitor

Was the client able to:

Maintain usual pattern of bowel functioning

Demonstrate behaviors of lifestyle changes to prevent developing problem

Yes ___ No ____Goals met ____Partially met ____Not met ____

client to maintain elimination diary, if appropriate

bowel pattern.

Delayed Surgical Recovery – Extension of the number of postoperative days required to initiate and perform activities that maintain life, health, and well being.

Assessment Diagnosis Planning Intervention Rationale EvaluationS> “Nahihirapan akong gumalaw, ang sakit ng katawan ko” as verbalized by the patient.

O> Evidence of interrupted healing of surgical area.Difficulty in moving about required help to complete self care.

Delayed surgical recovery r/t extensive/prolonged surgical procedures pain and postoperative surgical site infection AMB evidence of interrupted healing of surgical area, and difficult in moving about requires help to complete self care.

W/in 12O of nursing intervention the client will be able to:

Display complete healing of surgical area.

Be able to perform desired self care activities

Determine extent of surgical involvement of organs/tissues, age/development state of health

Assess nutritional status and current intake

Determine cultural expectations regarding recovery process and participation of client/others.

Note length of hospitalization and progress and compare with expectation for procedures and situation.

Recommend alternating

To provide anticipatory guidance in postoperative care

To determine if nutrition is adequate to support healing

Nursing Priority #1

Nursing Priority #3

To reduce fatigue

Was the client able to:

Display complete healing of surgical areaAble to perform desired self – care activities.

Yes ___ No ____Goals met ____Partially met ____Not met ____

activity with adequate rest periods.

Ineffective airway clearance - Inability to clear secretions or obstruction from the respiratory tract to maintain a clear airway.

Assessment Diagnosis Planning Intervention Rationale EvaluationS> “Nahihirapan akong huminga” as verbalized by the patient.

O> Diminished/ adventitious breath soundsChanges in respiratory rateDifficulty in vocalizingWide - eyed

Ineffective airway clearance r/t excessive mucus secretions AMB adventitious breath sounds, changes respiratory rate, Difficulty vocalizing, wide – eyed.

W/in 6O of nursing intervention the client will be able to:

Maintain airway patency.

Expectorate/clear secretions readily

Demonstrate absence/reduction of congestion w/breath sounds, clear, respiration, noiseless, improved oxygen exchange.

Demonstrate behavior to improved or maintain clear airway.

Monitor respirations and breath sounds, nothing rate and sounds (tachypsia stridor, crackles, wheezes)

Evaluate clients cough/ gag reflexes and swallowing ability

Suction nasal/tracheal/ oral pan

Encourage deep breathing and coughing exercises; splint chest/incision

Indicative of respiratory distress and or accumulation of secretions.

To determine ability to protect own airway.

To clear airway when excessive or viscous secretions are blocking airway or client is unable to swallow or cough effectively.

To maximize effort.

Was the client able to:

Maintain airway patency.Expectorate/clear secretions readily Demonstrate able/reduction of congestion, with breath sounds clear, respiration, noiseless, improved oxygen exchange. Demonstrate behaviors to improved or maintain clear airway.

Yes ___ No ____Goals met ____Partially met ____Not met ____

Increased fluid intake.

Ausculate breath sounds and assess air movement.

Hydration can help liquefy viscous secretions and improve secretion clearance.

To ascertain status and note progress

Risk for Sudden Infant Death Syndrome – Presence of risk factors for sudden death of an infants under 1 year of ageAssessment Diagnosis Planning Intervention Rationale EvaluationS>

O>

Risk for sudden Infant Death Syndrome r/t unknown etiology

W/in one day of nursing intervention the patient will be able to:

Verbalize understanding of modifiable factors

Make changes in environment to reduce risk of death occurring from the other factors

Fallow medically recommended prenatal and postnatal care.

Identify individual factors pertaining to situation.

Note whether mother smoke during pregnancy or is currently smoking

Recommend that infant most be placed on his or her back to sleep, both at

To determine modifiable or potentially modifiable factors that can be addressed and treated. SIDS is the most common cause of un explained death between the 2nd and 4th mos.

Smoking is known to negatively affect the fetus prenatally as well as after birth some reports indicate an increased risk of SIDS in babies of smoking mothers.

Research confirms that fever infants die of SIDS when they sleep on

Was the client able to:

Verbalize understanding of modifiable factorsMake changes in environment to reduce risk of death occurring from the other factors.Follow medically recommended prenatal and postnatal care

Yes ___ No ____Goals met ____Partially met ____Not met ____

night time and naptime.

Disease known facts about SIDS w/ parents.

their backs and that a side – lying position is not to be used.

Correct misconceptions and help reduce level of anxiety.

Deficient Knowledge – Absence of deficiency of cognitive information related to specific topic (lack of specific information necessary for clients /so(s) to make informed choices regarding condition/treatment/lifestyle changes.)

Assessment Diagnosis Planning Intervention Rationale EvaluationS> “I don’t want to learn and I don’t have any idea from what is it” as verbalized by the patient

O> Inaccurate follow- through of instruction/ performance of testInappropriate/ exaggerated behaviors.

Deficient knowledge r/t unfamiliarity w/in info. Resources and lack of interest in learning AMB Inaccurate follow through instruction/ performance of test Inappropriate / exaggerate behaviors

With in 12O of nursing intervention the client will be able to

Participate in learning process and exhibit increased Interest and also perform necessary procedures correctly and explain reasons for action.

Ascertain level of knowledge, including anticipatory needs

Determine clients ability / rediness and barriers to learning.

Determine the blocks of learning

Provide environment that is conducive to learning

Provide info about additional learning resources

Nursing Priority #1

Individual may not be physically, emotionally or mentally capable at this time.

Nursing Priority #2

Nursing Priority #8

May assist with further learning/ promote learning at own pace.

Was the client able to:

Participate in learning process.Exhibit increased interest and also perform necessary procedures correctly and explain reasons for action.

Yes ___ No ____Goals met ____Partially met ____Not met ____

Death Anxiety – Vague uneasy feeling of discomfort or dread generated by perception of a real or imagined threat to one’s existence.

Assessment Diagnosis Planning Intervention Rationale EvaluationS> “Ayokong mamatay” as verbalized by the patient.

Death anxiety r/t confronting reality of terminal disease and uncertainty of prognosis AMB “Ayokong mamatay” as verbalized by the patient.

With in 2 - 3O of nursing intervention the client will be able to

Identify and express feelings freely / effectively

Look toward / plan for the future one day at a time.

Formulate a plan dealing with individual concerns and eventualities of dying as appropriate.

Determine how client sees self in usual lifestyle role functioning and perception and meaning of anticipated loss to him or her and SO(s)

Ascertain correct knowledge of situation

Provide open and trusting relationship

Encourage expression of feelings. Acknowledge anxiety/fear. Do not deny or reassure client that everything will be all right. Be honest when answering

Nursing Priority #1

To identify misconceptions, lack of info, other pertinent issues

Nursing Priority #2

Enhance trust and therapeutic relationship.

Was the client able to:

Identify and express feelings freely/ effectively Look toward/plan for the future one day at a time.Formulate a plan dealing w/ individual concerns and eventually of dying as appropriate.

Yes ___ No ____Goals met ____Partially met ____Not met ____

question / providing information

Provide calm peaceful setting and privacy as appropriate.

Promotes relaxation and ability to deal with situation.

Risk for Situational Low Self – Esteem – At risk for developing negative perception of self – worth in response to a correct situation (Specify)

Assessment Diagnosis Planning Intervention Rationale EvaluationS>

O>

Risk for situational low self – esteem r/t behavior inconsistent with values and lack of recognition; AMB loss of self confidence.

With in 12O of nursing intervention the client will be able to:

Acknowledge factors that lead to possibility of feelings of low self – esteem.

Verbalize view of self as worthwhile, important person who functions well both interpersonally and occupationally.

Demonstrate self – confidence by setting realistic goals and actively participating in life situation

Identify clients basis sense of self – worth and image clients has of self – existential physical, psychological.

Determine client awareness of own responsibility for dealing w/situation personal / growth and so forth.

Verify client’s concept of self in relation to cultural/religious ideals.

Nursing Priority #1

Nursing Priority #1

Conflict between correct situation and these ideals may contribute to risk of low self – esteem.

Was the client able to:

Acknowledge factor that lead to possibility of feelings of low self – esteem.

Verbalized view of self as a worthwhile important person who functions well both interpersonally and occupationally.

Demonstrate self confidence by selling realistic goals and actively participating in life situation.

Yes ___ No ____Goals met ____Partially met ____Not met ____

Rediness for Enhanced Communication – a pattern of exchanging information and ideas with others that is sufficient for meeting one’s need and life goals, and can be strengthened.

Assessment Diagnosis Planning Intervention Rationale EvaluationS> “I was worthless, I may not existing.”

O> Able to speak/ or write a language Forms a words, phrases, sentences.Uses/ interprets non verbal cues appropriately

Rediness for enhanced communication r/t unknown etiology.

With in 2-3O of nursing client will be able to:

Verbalize or indicate an understanding of the communication process

Identify ways to improve communication.

Ascertain circumstances that result in client’s desire to improve communication.

Evaluate mental status

Determine comfort level in expression of feelings and concepts in nonproficient language.

Evaluate

Many factors are involved communication and identifying specific needs/expectations helps in developing realistic goals and determining likelihood of success.

Disorientation and psychotic conditions may be affecting speech and the communication of thoughts, needs and desires.

Concerns about language skills can impact perception of own ability to communication.

Communication

Was the client able to:

Verbalize or indicate an understanding of the communication process.

Identify ways to improve communication.

Yes ___ No ____Goals met ____Partially met ____Not met ____

congruency of verbal and nonverbal messages.

Pay attention to speaker. Be an active listener.

is enhanced when verbal and nonverbal messages are congruent.

The use of actives-listening communicates acceptance and respect for the client, establishing trust and promoting openers and honest expressions. It communicate that the belief of the client is a capable and competent person.

Rape - Trauma Syndrome – Sustained maladaptive response to a force violent sexual penetration against the victim’s will and consent (rape is not a sexual crime, but a crime of violence and identified as sexual assault. Although attacks

are most often directed toward women, men also may be victims.)Assessment Diagnosis Planning Intervention Rationale EvaluationS> I feel embarrass and I want to kill my self, as verbalized by the patientO>Physical traumaConfusionAgitationMood swingsSuicide attemptsDissocative disorders

Rape – Trauma Syndrome r/t emotional reactions AMB Physicall trauma, confusion, agitation, mood swings, suicide attempts, dissociative disorders.

With in 1 week of nursing intervention the client will be able to:

Deal appropriately with emotional reactions as evidenced by behavior and expression of feelings.

Report of absence of physical complications pain, and discomfort.

Verbalize positive self – image.

Verbalize recognition that incident was not of own doing.

Demonstrate appropriate changes in lifestyle (e.g.,

Observe for and elicit information about physical injury and assess stress – related symptoms, such as numbness, headache tightness in chest, nausea, pounding heart and so forth.

Provide psychological support by listening and remaining with the client does not want to take, accept silence.

Identify support persons for this individual.

Nursing Priority #1

May indicate silence reaction.

The client partner can be important to her or his recovery by being patient and confronting when partners

Was the client able to:

Deal appropriately with emotional reactions as evidenced by behavior and expression feelings.Report of absence of physical complications, pain and discomfort.Verbalize positive self – imageVerbalize recognition that incident was not of own doing.Demonstrate appropriate changes in lifestyle as necessary and seek/obtain support from SO(s) as needed.

Yes ___ No ____Goals met ____Partially met ____Not met ____

change in job/residence) as necessary and seek/obtain support from SO (s) as needed.

Allow the client to work through own kind adjustment. May be withdrawn or unwilling to talk; do not force the issue, but be available if needed.

talk through the incident, the relationship can be strengthened.

Nursing Priority #2

Rediness for Enhanced Coping – A pattern of cognitive and behavioral efforts to manage demands that is sufficient for well being and can be sthrengthened.

Assessment Diagnosis Planning Intervention Rationale EvaluationS> “I was so stress, hindi ko na alam gagawin ko” as verbalized by the patient

O>Uses a broad range of problem/ emotional – oriented strategies > uses spiritual resources.

Rediness for enhanced coping r/t unknown etiology AMB uses a broad range of problem/emotional oriented strategies, uses spiritual resources.

With in 2 – 5O of nursing intervention the client will be able to:

Assess current situation accurately.

Identify effective coping behaviors currently being used

Verbalize feeling congruent with behavior.

Evaluate ability to understand events, provide realistic appraisal of situation

Determine stresses that are currently affecting client.

Encourage client to create stress management program.

Provides info. About client’s perception, cognitive, ability, and whether the client’s is aware of the facts of the situation. This is essential for planning care.

Accurate identification of situation that client is dealing with provides info. For planning interventions to enhance coping abilities.

An individual program of relaxation, meditation, involvement with caring for

Was the client able to:

Assess current situation accuratelyIdentify effective coping behaviors currently being used.Verbalized feeling congruent with behaviors.

Yes ___ No ____Goals met ____Partially met ____Not met ____

others/pets will enhanced coping skills and strengthen client ability to manage challenging situation.

Risk for Impaired religiosity – At risk for an impaired ability to exercise reliance on religious beliefs and /on participate in rituals of a particular faith tradition.

Assessment Diagnosis Planning Intervention Rationale EvaluationS>

O>

Risk for Impaired religiosity r/t unknown etiology

With in 1 day of nursing interventions the client will be able to:

Express understanding of relation of situation/health status to thoughts and feelings of concerns about ability to participate in desired religious activity.

Determine clients usual religious/spiritual beliefs, past or current involvement in specific church activities.

Assess lack of transportation/ environmental barriers to participation in desired religious activities.

Have client identify and prioritize current/ immediate needs.

Nursing Priority #1

Nursing Priority #2

Dealing with current need is easier than trying to predict the future.

Was the client able to:

Express understanding of relationship of situational health status to thoughts and feelings of concerns. About to participate in desired religious activities.

Yes ___ No ____Goals met ____Partially met ____Not met ____

NONCOMPLIANCE – Behavior of person and/or caregiver that fails to concede with a health promoting or therapeutic plan agreed on by the person (and/or the family and/or the community) And healthcare professional. In the presence of an agreed – on health promoting or therapeutic plan, person’s or caregiver behavior is fully or partially non adherent

and may lead to clinically or ineffective or partially outcomes.Assessment Diagnosis Planning Intervention Rationale EvaluationS> “Nahihirapan po akong magtrabaho pati na rin sa pagdedesisyon” as verbalized by the patient.

O> Behavior indicative of failure to adhereFailure to progressFailure to keep appointments.

Noncompliance r/t personal/developmental abilities AMB behavior indicative of failure to adhere, failure to progress and failure to keep appointments.

With in one day of nursing interventions the client will be able to:

Verbalize accurate knowledge of condition and understanding of treatment regimen.

Verbalize commitment to mutually agreed upon goals and treatment plan

Demonstrate progress towards desired outcomes/ goals.

Provide for continuity of care in and out of the hospital / care setting including long range plans.

Provide information and help client to know where and how to find it on own.

Accept the client choice /point of view even if it appears to be self destructive. Avoid confrontation regarding beliefs.

Determine social

To supports trust facilitate progress towards goals.

To promote independence and encourage informed decision making

To maintain open communication

Nursing Priority #1

Was the client able to:

Verbalize accurate knowledge of condition and understanding of treatment regimen.

Verbalize commitment to mutually agreed upon goals and treatment plan

Demonstrate progress towards desired outcomes /goals

Yes ___ No ____Goals met ____Partially met ____Not met ____

characteristics, demographic and educational factors, as well as personality of the client.