Goals

Date/Tim Cues Needs Nursing Scientific Objectives Nursing Rationale Evaluation

e Diagnosis Basis Criteria Interventions

Nov. 30, Sub. N Hyperthermia Pyrogens Within 4 hours of 1.Establish rapport with 1.Promotes cooperation in Within 4 hours of
2015 U related to cause a rise in nursing the client and parents. the nursing care. nursing
“init kayo T inflammatory body interventions, interventions,
@ akonganak R process temperature, client will be able 2.Monitor vital signs 2.Helps to identify the client was able to
nurse.”, as I it also acts as to report and development of the client’s report and show
6 pm verbalized by T antigen show 3.Note presence/absence VS manifestations
the mother. I triggering manifestations of sweating that fever was
O immune that fever is 3.Evaporation is decreased relieved as
Obj. N system relieved as 4.Provide tepid sponge by environmental factors evidenced by:
Temp: 40°c A responses. evidenced by: bath as well as body factors
RR:32 cpm L The producing loss of ability to Verbalization of
PR: 127 bpm - hypothalamus Verbalization of 5.Encourage to increase sweat the client:
-flushed skin M reacts to raise feeling well oral fluid intake up to 2 “dili na init akong
-dry mucous E the set point liters a day 4.To reduce body pamati ate nurse.”
membranes T and the body VS within normal temperature through the
-muscle A respond by range 6.Promote bed rest process of conduction VS of:
rigidity B producing Temp= 36.7°c
-chills O heat. Absence of 7.Regulate IVF as 5.Water regulates body RR= 25 cpm
-malaise L muscular indicated by physician temp. PR= 92
I Source: rigidity/chills
C Fundamentals 8.Administer antipyretics 6.To promote relaxation Absence of
of Nursing Absence of as ordered by physician muscular
P -Harry & flushing such as paracetamol 7.To replenish fluid losses rigidity/chills
A Perry during shivering chills
T 9.Monitor intake and Normal
T output 8.To treat underlying complexion of
E causes skin
R 10. Provide high-calorie
N diet such as chicken, 9.To know the fluid
bread and rice balance of the body.

10. To meet increased

metabolic demands.
 Date/ Goals
Time Cues Needs Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Basis Criteria Interventions
Sub. C Acute pain Acute pain After 4 hours ●Monitor skin ●which are After 4 hours of nursing
”sigeg O related to Ability to of nursing color/temperat usually altered intervention the patient
12/1/15 sakit ang G dengue as control intervention, ure. in acute pain. was able to experience
@ akong N manifested internal/exte the patient ●Administer gradual relief of pain as
9:30am tiyan” as I by facial rnal will be able to medicine as ●Only the evidenced by no
verbalized T grimacing, environment experience doctor's order. client can abdominal cramp.
by patient. I guarding to maintain gradual relief ● Maintain judge the level
V behavior, comfort. pain personal and distress of
Obj. E restlessness as evidenced hygiene. pain; pain
Pain - and verbal by: ●Encourage management
scale:8ǀ10 P report of ● normal pain verbalization should be a
●Facial E pain felt in scale. of feelings team approach
grimacing R the lower about the pain. that includes
C abdominal ● Teach client the client.
●restlessne E region. divertional
ss P activities.
T ● Advise
●verbal U breathing
report of A exercise.
acute pain L ● monitor V/S
and pain scale.
●guarding P ● Assess the
behavior A patient pain
on the right T scale and
lower E perception.
extremity. R ● avoid color
N drinks.
 Date/ Goals
Time Cues Needs Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Basis Criteria Interventions
12/1/15 “usahay H Joint Pain At risk of After span of ˃assess clients ˃to identify After span of care the
@10:30 magsakit E Related to injury as a care the muscle risk for falls patient will be able to
akong A risk for result of patient will be strength, gross demonstrate behaviors as
tuhod ug L injury environment able to and fine motor evidenced by lifestyle
likod T al demonstrate coordination ˃to prevent changes to reduce risk
tungod H conditions behaviors as ˃ensure that infections factors and protect self
atong na P interacting evidenced by pathway to from injury
disgrasya E with the lifestyle bathroom is
ko sa R individuals changes to unobstructed
motor”as C adaptive and reduce risk and properly
verbalized E defensive factors and lighted
by the pt. P resources protect self ˃administer
T from injury. medications as
I order
O ˃maintain a
N good hygiene
 Date/ Goals
Time Cues Needs Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Basis Criteria Interventions
12/01/15 Subj.: N Risk for Fluid volume Within 8 hours 1.Establish 1.To gain trust GOAL MET
@ “Nagsuka U fluid volume deficit occurs of NI, patient rapport. and alleviate
10:00 am siya T deficit from a loss of will be able to anxiety. Within 8 hours of NI, patient
gahapon og R r/t vomiting, body fluid or maintain 2.Monitor VS as was able to maintain
nagdugo I epistaxis the shift of adequate fluid indicated. 2.Change in adequate fluid volume A/E
iyang T 2* dengue fluids into the volume A/E by:
VS may
ilong”, as I fever third space, by: 3.Monitor  Vs within normal limits
 Vs within
indicate
verbalized O or from a accurate I/O.  Balanced I/O
hypovolemia.
by the N reduced fluid normal  Good skin turgor
mother. A intake. Once limits 4.Assess skin  Pink, moist mucus
L common  Balanced turgor, mucus 3.Indicates membranes
Obj.: / source of I/O membranes, excessive fluid  Enumerated ways to
 Letharg M fluid loss is  Good skin capillary refill. loss or monitor and prevent
y noted E nausea and turgor resultant of deficit and patients
 Dry skin T vomiting,  Pink, moist 5.Monitor pt.’s dehydration. verbalization of
noted A bleeding, mucus weight daily. “Magsige nako og inom
 Dry lips B excessive membranes 4.Indicates tubig.”
noted O urination. In  Enumerate 6.Administer
dehydration.
 VS of L dengue fever, ways to and monitor IV
T-38.6 I signs and monitor fluids as
C symptoms ordered. 5.Weight is a
BP- and prevent
100/70 that could 7.Encourage to useful
deficit such
HR-78 P manifest are as increase increase OFI of indicator for
RR-24 A vomiting and OFI up to fluid balance.
T frequent 8 glasses/day.
T bleeding 6.To replace
E from GI tract 8.Encourage to active fluid and
R in the form of eat green leafy electrolyte
N hematemesis veggies such as loss.
or melena pechay and
that may lead organ meats.
to fluid loss. 7.To prevent
9.Provide fresh dehydration.
Gulamick,M. water and oral 8.Green leafy
, Myers, J. fluids such as veggies and
2007 Nursing milk, fruit juice organ meats
Care Plan: preferred by are rich in iron
Nursing patient. for the blood.
Diagnosis
and
Intervention 10.Explain 9.Oral route is
6th ed. importance of preferred for
proper nutrition maintaining
and hydration. fluid balance.
11.Provide
10.To instill
frequent oral
care such as knowledge to
using soft pt. and SO
toothbrush. regarding fluid
balance.
12.Apply TSB.
11.To prevent
13.Monitor lab injury from
studies (Hb, Hct, dryness.
RBC count,
platelet count) 12.To
moisturize
skin.

13.To monitor
effectiveness
of therapy.
 Goals
Date/Time Cues Needs Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Basis Criteria Interventions
A
12/1/15 Subj: C Fatigue r/t Both bacterial After/within 8hrs -established rapport -to gain cooperation and “Partially goal
T increased and viral span of care client to the client. alleviate anxiety. met”
@ “Kapoyanko I metabolic infections can able to develop -assess vital sing. -for easily monitor any
usahaymagli V rate increase the good progress -enhances changes vital sing.
11:48am hok gusto I secondary metabolic rate such as: commitment to -encourage the patient
langnako T to dengue of the body promoting optimal to promote goal for - Verbalizes
mag higda” Y virus which - increased energy outcomes. good outcome increased energy
as verbalized - infection decreases the and enhance self -encourage nutritious -encourage eating and improved
by client. E energy food to promote nutritious food high in well-being.
esteem.
X Source: levels of the energy. energy such as honey, -moderately
Obj: E body which -improvement of -assess the patient apple, orange, sweet improved during
R American then leads to all activities daily ability to performed potato. activity level
-lack of C Journal of tiredness or living (ADLs) activities of daily -enhance that patient -maintain the
energy I Clinical fatigue. living(ADLs). will plan all daily peaceful
-warm skin S Nutrition -avoid client into -promotes sense of activity environment in
to touch E discomfort control and improves -assist client to identify client.
-limited environment. self-esteem. appropriate coping -communication
ROM P -teach client behaviors. in client can
-client able to
-irritability A strategies for energy -energy conservation is improved her
- dozing T expresses his conservation. to preserve more energy feeling /situation.
-drowsy T feelings. -encourage to drink to response our body -showing the
-droopy eyes E fluids. needs ability to
-client able do a
-flushed skin R -provide a sound and -drinking in high in development
-poor N simple task to comfortable electrolyte can simple activity.
concentratio provide own environment promotes more energy
n needs. conducive for resting. -providing comfortable
-T 39.1 -fatigue can be environment increase
RR 32 consequences of and resting period
PR 127 exacerbated by sleep -determine presences
deprivation. degree of sleep
-avoid drinks disturbances
containing caffeine. -drinking more caffeine
-provide diversional can affect resting period
activities like open -jovial communication
and jovial elevate stress and
communication. promotes good
-encourage the client perception
to get adequate sleep.
-certain meds -sleep and adequate rest
including prescription can improve the client
esp. beta adrenergic status
blockers and over the - review the
counter drug herbal medications for side
supplements are effects may cause
known to cause fatigue
exacerbate fatigue. -depression also trigger,
-monitor for so alter the client
depression as a perception.
possible contribution -client must know their
for fatigue. limitations in the daily
-determine the client activities to prevent
physical limitations. more complication.
-observe the -check the place before
environment for doing the activities that
discomfort during can harm to client.
activities. -visitors are to many
-limit the number and also disturbed our
disturbance by client during rest and
visitors if they sleep pattern.
want/need. -scale the fatigue in our
-ask client to rate client to determine
fatigue from 1 to 10. within normal range.
-some studies fatigue -age , gender ,and
often in females than development stage can
male also the stage of affect fatigue.
adolescences and the
condition.