for educational purpose only..

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.