Cues Nursing Diagnosis Rationale Nursing Objectives Nursing Rationale Evaluation

Subjective/ Intervention
Objective
S: “Masakit ang tahi Acute pain r/t post op Unpleasant sensory After 2 hours Provide To alleviate pain by After 2 hours
ko “ as verbalized by surgical incision due to and emotional of Nursing Comfort promoting non- of Nursing
the client. Salpingectomy as experience arising Interventions Measures such pharmacological Interventions
evidenced by facial from actual or potential the patient’s as repositioning pain the patient’s
grimace with a pain tissue damage. pain scale will or quiet management pain scale
scale 0f 4. decrease from environment decreased
4 to 2. from 4 to 2

Instruct the To distract Goal is met

patient to use attention and
O: relaxation reduce tension
>Pain scale 4/10 techniques and
encourage
>(+) facial grimace diversional
activity such as
>Expressive Behavior listening to
such as sighing. music, watching
television and
>limited movement socialization
with others.
>20 RR
Encourage It promotes
patient to do healing of
Deep Breathing surgical wounds
Exercise by
demonstrating
how to do
it(every 4 hour
daily with 5-10
breaths during
exercise
 Cues Nursing Diagnosis Rationale Nursing Objectives Nursing Rationale Evaluation
Subjective/ Intervention
Objective
S: “Hindi ako Disturbed Sleep Time-limited After 1-3 hours nursing Assess past patterns of Sleep patterns are Client demonstrated an
masyadong Pattern r/t Insomnia disruption of sleep intervention the client sleep in normal unique to each optimal balance
nakakatulog kasi 1am (natural, periodic will able to: environment: amount, individual. of rest and
ako tas 4am gigising suspension of bedtime rituals, depth, activity at
nako. Madalas ding consciousness) amount Demonstrate an length, positions, aids, least 2-3 hours
putolputol din tulog and quality. optimal balance and interfering agents. of uninterrupted
ko” as verbalized by of rest and sleep.
the client. activity at Assess patient’s Knowing the specific
least 2-3 hours perception of cause of etiological factor will
O: of uninterrupted sleep difficulty and guide appropriate
>restlessness sleep. possible relief therapy.
measures to facilitate
>Dark circles treatment. For short-
under eyes term problems, patients
may have insight into
the etiological factors
>irritable of the problem (e.g.,
fear over results of a
diagnostic test, concern
over a daughter getting
divorced, depression
over the loss of a loved
one).

Instruct patient to Promotes regulation of

follow as consistent a the circadian rhythm,
daily schedule for and reduces the energy
retiring and arising as required for adaptation
possible. to changes.
Instruct to avoid heavy Though hunger can
meals, alcohol, also keep one awake,
caffeine, or smoking gastric digestion and
before retiring. stimulation from
caffeine and nicotine
can disturb sleep.

Increase daytime This reduces stress and

physical activities as promotes sleep.
indicated.

Instruct to avoid Over fatigue may

strenuous activity cause insomnia.
before bedtime.

Suggest use of Milk contains L-

soporifics such as tryptophan, which
milk. facilitates sleep.
 Cues Nursing Diagnosis Rationale Nursing Objectives Nursing Rationale Evaluation
Subjective/ Intervention
Objective
S: “ Lagi akong Imbalanced Intake of nutrients After 2 hours of Monitor or explore Many psychological, Client verbalized and
walang gana at Nutrition: Less than insufficient to meet nursing intervention attitudes toward psychosocial, and demonstrated selection
tinatamad kumain kasi Body Requirements metabolic needs the client will eating and food. cultural factors of foods or meals that
lagging work. Tapos r/t Unwillingness to Verbalizes and determine the type, will achieve of
hindi din ako nakakaen Demonstrates cessation of weight
eat; loss of appetite; amount, and
ng healthy.” as selection of foods or loss.
verbalized by the
lack of information appropriateness of
meals that will food consumed.
client. achieve a cessation
of weight loss. Ensure a pleasant
O: Assist patient with environment,
meals as needed. facilitate proper
>body weakness
position, and provide
> depression good oral hygiene
and dentition.
> boredom Elevating the head of
bed 30 degrees aids
>wt. in swallowing and
reduces risk of
aspiration.

Attention to the
Provide social aspects of
companionship eating is important in
during mealtime. both the hospital and
home settings.
Encourage small fre- Maximizes nutrient
quent meals with intake
foods high in protein without undue
and carbohydrates. fatigue or
energy expenditure
from
eating large meals,
and
reduces gastric
irritation.

Encourage patient Determination of

participation in type, amount, and
recording food intake pattern of food or
using a daily log. fluid intake is
facilitated.

During aggressive
Weigh patient nutritional support,
weekly. patient can gain up to
0.5 pound/day.

Document actual Patients may be

weight; do not unaware of their
estimate. actual weight or
weight loss due to
estimating weight.