The document contains multiple sections from nursing notes on different patients. It includes assessments of patients' symptoms and concerns, nursing diagnoses, objectives for interventions, details of interventions provided and their rationales, and evaluations of outcomes. Key information includes patients presenting with anxiety about their health, pain, knowledge deficits, and weight gain related to changes in diet. Nurses addressed these issues through monitoring, education, and lifestyle counseling aimed at reducing anxiety and pain levels, increasing knowledge, and identifying unhealthy eating habits within 8 hours of interventions.

1. IX. NCP
June 27, 2014
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
" hindi ko alam
kung
makakapagtrabaho
na ako kaagad
pagkagaling ko eh"
as verbalized by the
patient
OBJECTIVES:
-Vital signs,
BP130/90
Temp.36.2c
CR- 64
RR-20
-restlessness
-difficulty in
sleeping
-fatigue
Anxiety related to
threat to/ or change in
health status
Within 8 hours of
nursing
interventions the
patient will appear
relaxed and the
level of anxiety will
reduced to a
manageable level
-Monitor vital signs(e.g.,
rapid or irregular pulse,
rapid breathing)
-Use presence, touch,
verbalization or
demeanour to remind
client and to encourage
expressions or
clarification of needs,
concerns, unknowns
’and questions
- Accept client’s
defences, do not
confront, and argue and
debate
-Allow and reinforce
clients personal reaction
towards the threatens to
wellbeing
-Explain everything
necessary regarding the
disease
-To identify physical
responses associated
with both medical and
emotional conditions
-Being supportive and
approachable
encourages
communication
-If defenses are not
threatened, the client
may feel safe enough
to look at the behavior
-Talking or otherwise
expressing feeling
reduces anxiety
-To educate the patient
regarding the disease
to reduce anxiety
After 8 hours of
nursing
interventions
the patient
appeared
relaxed and the
level of anxiety
will reduced to
a manageable
level

2. June 23,2014
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
“ m e d y o
m a s a k i t
y u n g
t i a y a n k o "
as verbalized by the
patient
OBJECTIVES:
-Vital signs,
BP130/90
Temp.36.2c
CR- 64
RR-20
-pain scale: 6/ 10
- -difficulty in
sleeping
Acute pain related to
irritation of the
mucosa and muscle
spasms.
Within 8 hours of
nursing
interventions the
Client expresses
pain diminished or
disappeared.
Encourage clients to
avoid foods / drinks that
irritate the gastric
mucosa: caffeine and
alcohol.
Encourage clients to use
the meals and snacks at
regular intervals
-Instruct patient to stop
smoking
Give drug therapy
according to the
program
Instruct to avoid drugs
are sold freely,
especially those
containing salicylates.
-to stimulate the
secretion of
hydrochloric acid.
-Schedule regular
eating helps retain
food particles in the
stomach that helps
neutralize the acidity
of gastric secretions.
-Smoking can
stimulate ulcer
recurrence.
Medicines containing
salicylates may irritate
the gastric mucosa.
After 8 hours of
nursing
interventions
the Client
expressed pain
diminished or
disappeared.

3. June 22, 2014
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
" ano bang mga
dapat kong gawin
para maiwasan na
yung pag sakit ng
tiyan ko?" as
verbalized by the
patient
OBJECTIVES:
-sighing
-restlessness
Knowledge Deficit:
the prevention and
treatment of
symptoms related to
the condition of
inadequate
information.
Within 8 hours of
nursing
interventions
Clients gain
knowledge about
prevention and
management.
Assess the level of
knowledge and
readiness to learn from
clients.
Teach the required
information: Use words
that correspond with the
level of knowledge of
the client. Choose a time
when most convenient
and interested clients.
Limit counselling
sessions to 30 minutes
or less.
Assure the client that the
disease can be
overcome.
- Desire to learn
depends on the
physical condition of
the client, the level of
anxiety and mental
readiness
-Individualization
counseling improve
learning.
-Gives confidence can
have a positive
influence on behavior
change.
Within 8 hours
of nursing
interventions
Clients gained
knowledge
about
prevention and
management

4. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
" hindi ko alam
kung
makakapagtrabaho
na ako kaagad
pagkagaling ko eh"
as verbalized by the
patient
OBJECTIVES:
-Vital signs,
BP130/90
Temp.36.2c
CR- 64
RR-20
-restlessness
-difficulty in
sleeping
-fatigue
Anxiety related to
threat to/ or change in
health status
Within 8 hours of
nursing
interventions the
patient will appear
relaxed and the
level of anxiety will
reduced to a
manageable level
-Monitor vital signs(e.g.,
rapid or irregular pulse,
rapid breathing)
-Use presence, touch,
verbalization or
demeanour to remind
client and to encourage
expressions or
clarification of needs,
concerns, unknowns
’and questions
- Accept client’s
defences, do not
confront, and argue and
debate
-Allow and reinforce
clients personal reaction
towards the threatens to
wellbeing
-Explain everything
necessary regarding the
disease
-To identify physical
responses associated
with both medical and
emotional conditions
-Being supportive and
approachable
encourages
communication
-If defenses are not
threatened, the client
may feel safe enough
to look at the behavior
-Talking or otherwise
expressing feeling
reduces anxiety
-To educate the patient
regarding the disease
to reduce anxiety
After 8 hours of
nursing
interventions
the patient
appeared
relaxed and the
level of anxiety
will reduced to
a manageable
level

5. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
" mas madalas na
ko kumain ngayon
kaysa dati kasi pag
sumasakit na yung
tiyan ko, ikakain ko
lang para mawala."
as verbalized by the
patient
OBJECTIVES:
- Wt: 61 kg (may
29,)
Wt: 63 kg (june 27)
Imbalanced Nutrition
more than body
requirements related
to changes in diet
Within 8 hours of
nursing
interventions the
patient will
Identifies eating
habits that
contribute to weight
gain.
Determine current
eating patterns by
having keep a
Diary of what, when,
and where she eats.
Determine current
eating patterns by
having keep a
Diary of what, when,
and where she eats.
Within 8 hours
of nursing
interventions
the patient will
Identifies eating
habits that
Contribute to
weight gain.