Parameters for Nursing Goals and Nursing Intervention

Rationale Nursing Outcomes

Assessment Diagnosis Objectives
Subjective Data: Risk for After 8 hours of nursing Independent: - Monitoring Goal met:
Fluid intervention the patients will vital signs helps to
“Mga 2 aldaw na kaya po Volume be able to lessen the - Monitor identify the wellbeing After 8 hours of nursing
akong pirming nagsusuka Deficit related to episodes of vomiting and vital signs for of the patient. interventions, the
exaggerated nausea. tachycardia, patient’s episodes of
kaya nag pa check up na
episodes of - Assessing the vomiting and nausea was
kami” as stated by the hypotension, and fever
vomiting skin and mucous lessened.
patient due to dehydration. membrane of the
patient helps to know
Objective Data: - Assess skin turgor
for the signs of
and mucous membranes.
dehydration.
The patient shows
exaggerated nausea and - Provide a - A well-
vomiting. well-ventilated ventilated
environment for the environment helps the
 Watery vomit patient to relax.
(4-5 x/day) patient
- Vomiting
- Prepare a
episodes will likely
basin at the bedside of
occur any time so
the patient having an emergency
basin at the bedside is
mostly needed.

Establishing an IV line
 Dependent: helps to maintain the
fluid volume of the
- Establish an IV patient.
line, and administer IV
fluids as prescribed by - Administering
the physician. antiemetic to the
patient helps to
- Medicate with prevent vomiting or
antiemetic as prescribed nausea
by the physician.
Administer
intramuscularly (IM).
Subjective data: Fever related to After 6 hours of nursing Independent: - Monitoring Goal met:
Infection intervention, the patients the patient’s vital
“Kang na-admit nalang temperature will be lessened - Monitor the After 6 hours of nursing
signs helps to have a
man po ako tigkalintura” from 37.8 °C to 36.6 °C patients vital signs every interventions, the
baseline data for any
as verbalized by the 2 hours patients’
improvement.
patient temperature was
- Provide a lessened from 37.8 °C to
- A good and
well-ventilated and quiet 36.6 °C.
quiet
environment to the
environment gives
Objective Data: patient
comfort to the patient
 Temperature- - Position the and free them from
37.8 °C stress which can
patient on a side lying
 White Blood
position comfortably affect their condition
cells- 26.7
10e3/uL (H)
- Advise the client - A comfortable
 Neutrophils –
to take the medications position helps the
87.6 % (H)
 Lymphocytes- 5.6 on time and properly patient to relax and
% (L) rest well
- Encourage the
significant other/family - Taking the
members to wipe the medications correctly
body of the patient using helps to avoid any
error and improved
a wet towel.
the wellbeing of the
patient
- Instruct the
patient to eat healthy -Bathing the
foods patient using a wet
towel helps to elevate
- Advise the patient the temperature.
to drink at least 1.5 liters
of water / day - Eating healthy foods
gives enough
nutrition for the
patient to recover fast
Dependent:
- Drinking
- Administer enough water helps to
paracetamol as ordered get rid of wastes from
by the physician our body.

- Administer
antibiotics as ordered by - Paracetamol
the physician helps to lowers the
temperature of the
- Refer to the patient
doctor if fever got
 - Antibiotics helps to
treat and prevent the
infection from
spreading

- Referral is
needed if the infection
got worse
worse/not decreasing
Subjective data: Pain related to After 6 hours of nursing Independent: Goal met:
vomiting interventions, the patients After 8 hours of nursing
“Nagkukulog po kaya igdi pain will be lessen from 6/10 - monitor the patients - Monitoring interventions, the
banda sa tulak ko pag to 4/10 on the epigastric vital signs every 2 hours the vital signs helps to patients pain was
nasusuka ako, tapos pati region and from 5/10 to 2/10 identify if there’s any lessened from 8/10 to
likod ko nagkukulog man on the flank region - Assess the pain of the abnormalities to the 6/10 and from 5/10 to
kaya nag digdi na po patient by its location, patients condition 2/10 on the flank
kami sa hospital ta intensity and quality
mapahiling” as stated by - Assessing the pain of
the patient - Provide a quiet and the patient to know
ventilated environment what are the possible
measure to perform
Objective data: - Advise the patient to do
bed rest - A quiet and
 RR-22 well-ventilated
 Pain scale of 6/10 - Provide a warm environment gives
on the epigastric compress to the patient comfort and
region relaxation to the
 Pain scale of 5/10 - Instruct the significant patient
on flank region other or family members
on the flank to reposition the patient - Bed rest is
  Stabbing pain and do back rubs needed for the
patient experiencing
pain to elevate the
Dependent: pain
- Administer pain reliever
to the patient as - Warm
prescribed by the compress helps to
physician lessen the pain that
the patient is
experiencing

- Repositioning
and doing back rubs
to the patient helps to
lessen the pain and
gives comfort to the
patient

- Pain reliever
helps to alleviates the
pain
Subjective Data: Knowledge deficit Short Term: Independent: Short Term:
related to Proper Goal met:
“Sarong beses man lang Hygiene After 4 hours of nursing - Assess the - The knowledge After 4 hours of nursing
interventions, the knowledge level of the level of the patient interventions, the patient
kaya po ako
patient will be able to patient may affect how was able to verbalize the
nakakahugas” as he/she perceived the
verbalize the importance of importance of proper
verbalized by the patient information.
proper hygiene - Note other hygiene.
factors that influences - Factors like age,
Objective data: Long term:
the patient financial status,
 White blood Goal partially met:
affects the patients
cells- 26.70 10e3/uL (H) capability to perform After 3 days of nursing
 Neutrophils – - Discuss to the proper hygiene interventions, the patient
Long Term: was able to perform proper
87.6 % (H) client the importance of
hygiene but not
 Lymphocytes- 5.6 After 3 days of nursing proper hygiene - Washing the genitals consistently practice.
% (L) interventions, the from top to bottom
patient will be able to perform - Advise the client helps to prevent the
 Eosonophils – 8.4 the proper hygiene to wash infection from
% (H) their genitals from top to spreading and entering
bottom the urinary system

- Encourage the - Drinking and eating

patient to eat high fiber high fiber foods like
bananas and oats
foods and drink enough
contains good bacteria
water/ day that helps to cleanse
the body from harmful
pathogens