Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: “ Madalas akong Sleep After 8 hours Instruct the Voiding before After 8 hours of nursing
nagigising ng gabi pag disturbance of nursing mother to void bedtime may intervention, the client had
nakakarinig ako ng mga related to intervention before limit the sleep improved sleeping pattern
ingay at madalas akong urinary the client will sleeping. disturbance as evidence by:
tumatayo nang madaling frequency improve sleep brought about
araw para umihi kase kapag related to pattern as by urinary
hindi ako umihi nasakit yung post-partum. evidence by: Provide a frequency. Absence of Eye bags and
pantog ko “ as verbalized by quiet frequent yawning.
the patient. Absence of environment A quiet
Eye bags and conducive for environment
Objective: frequent sleeping. promotes Absence of Pain in Bladder
Pain Scale: 7/10 yawning. continuation related to Urination.
Promote use of sleep
of bedtime without
rituals such as disturbances.
drinking glass,
taking a bath Promotes
or reading a relaxation and
book. readiness.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: “ Nahihirapan Impaired gas After four Assess patient Manifestation of After four hours of
huminga ang baby ko dahil exchange r/t hours of VS. respiratory distress is nursing
sa ubo” as verbalized by the collection of nursing dependent on interventions, the
mother. secretions interventions, Elevate head indicative of the patient will achieve
affecting the patient of the bed and degree of lung timely resolution of
oxygen will achieve change involvement and current infection
Objective: exchange timely position underlying general without
Dyspnea across alveolar resolution of frequently. status. complications.
Tachycardia membrane. current
VS: infection Limit visitors High fever greatly
Temperature: 37.7®C without as indicated. increases metabolic
Pulse Rate: 125 bpm complications. demands and oxygen
RR: 50cpm consumption and
alters cellular
oxygenation.

Reduces likelihood of
exposure to other
infectious pathogens.
Assesment Diagnosis Planning Intervention Rationale Evaluation
SUBJECTIVE: Risk for After 8 hours Wash hands Reduces risk of cross After 8 hours of
infection of before or after contamination nursing
“Walng gana dumede ang related nursing each care because gloves may interventions,
anak ko, parang mainit sya to interventions, activity, even have noticeable the patient was
at matamlay” as verbalized compromised the patient gloves are defects, get torn or able to achieve
by the patient. immune will used. damaged during use. timely healing
system. achieve timely and free from
OBJECTIVE: healing and further
Increased body free Limit use of infection.
temperature. from further invasive Prevents spread of
infection. devices or infection via
Increased respiratory rate. procedure as airborne droplets.
possible. May provide clue to
V/S taken as follows: portal entry, type of
T: 37.7 primary infecting
P: 130 Inspect organisms, as well as
R: 45 wounds or site early identification
of invasive secondary infection.
devices,
paying
particular Prevents
attention to introduction of
parenteral bacteria, reducing
lines. risk of nosocomial
infection.

Maintain
sterile Chills often precede
technique temperature spikes
when changing in presence of
dressings, generalized
suctioning or infection.
providing site
care.

Provide tepid
sponge bath
and avoid use
of alcohol.