GOLEZ, Steffi Gabrielle R.

4NUR-2 / RLE-2

ASSESSMENT NURSING SCIENTIFIC GOALS / NURSING RATIONALE EVALUATION

DIAGNOSIS ANALYSIS OBJECTIVES INTERVENTIONS
Subjective: Acute pain Gastritis is a At the end of Independent: At the end of
“Ang sakit ng related to series of the 8-hour the 8-hour shift
tiyan ko.” As inflammation condition that shift of 1. establish 1. to facilitate of rendering
verbalized by of gastric present with rendering rapport cooperation nursing care,
the patient. mucosa as inflammation nursing care as well as to the patient was
evidenced by of the gastric patient will be gain patient’s relieved from
6 out of 10 recurrent mucosa. relieve from trust pain
pain scale abdominal Usually pain
pain stems from 2. Note for the 2. To determine
Objective: ingestion of a location, the nursing
>Facial corrosive, scale, care to be
Grimace erosive, or intensity and given to the
>Restlessness infectious onset of pain patient.
substance
Following VS 3. Maintain a 3. To minimize
as follows: calm and stimulus that
>BP : 110/70 quite could
>Temp: 38 environment. aggravate the
>PR: 88 bpm condition of
>RR: 20 bpm the patient

4. To add
comfort to
4. Provide a the patient
dim and
light but
 providing
good
ventilation. 5. To note
changes that
5. take and can affect the
record vital patient’s
signs condition

6. To promote
optimum
wellness
6. provide
health
teachings
such as:
 increase oral
fluid intake
 emphasize
the
importance
of
proper
hygiene

Dependent:
1. To assure
that the body
1. to regulate receives
IVF as accurate
ordered amount of
fluids and
electrolyte

2. To aid in the
easy
2. to give due recovery
medications
3. To serve as a
guide in
3. instructed on doing self-
home meds medication
that promotes
independence
ASSESSMENT NURSING SCIENTIFIC GOALS / NURSING RATIONALE EVALUATION
DIAGNOSIS ANALYSIS OBJECTIVES INTERVENTIONS
Subjective: Deficient Deficient After 8 hours Independent: After 8 hours of
“Naka dami fluid volume Fluid Volume of nursing nursing
akong suka related to is decreased intervention, 1. Assess 1. To monitor intervention, no
kaya vomiting intravascular, no patient's for other hypovolemic
nagpadala na interstitial, hypovolemic condition signs and shock was
ko ditto sa and/or shock and no symptoms noted and that
ospital at intracellular signs of the mucosa of
nanghihina fluid. This dehydration 2. Assess likes 2. To promote the patient was
ako.” As refers to will be noted. and dislikes, hydration moist,
verbalized by dehydration, provide indicating no
the patient. water loss favorite fluids signs of
alone without dehydration.
Objective: change in 3. Weight patient 3. Changes in
5x vomiting sodium daily weight can
(+) Dry lips provide
(+) Anorexia information
(+) Decrease in fluid
fluid intake balance and
the adequacy
Following VS of fluid
as follows: volume
>BP : 110/70 replacement
>Temp: 38
>PR: 88 bpm 4. Encourage 4. For hydration
>RR: 20 bpm increase fluid
intake
providing
appealing
liquids
5. Encourage to 5. For hydration
eat foods with
high fluid
content, such
as
watermelon,
grapes

6. Encourage to 6. To prevent
eat banana, diarrhea, for
rice, apple, stool
toast formation

7. Encourage to 7. To prevent
avoid food further
that cause dehydration
dehydration
such as coffee,
tea

8. Ensure 8. Accurate
accurate records are
intake and critical in
output assessing the
monitoring patient’s
fluid balance

9. Maintain on 9. Initial goal is

IVF hydration to correct
circulatory
volume
deficit.
 Isotonic
saline will
rapidly
expand
extracellular
fluid volume.
The
secondary
goal,
correction of
water deficit,
is usually
accomplished
by a
hypotonic
solution

10. Ensure proper 10. To ensure

IVF regulation that there is
adequate
hydration
Dependent:

11. Antibiotics 11. To aid in

given as preventing
ordered infection

12. Vitamins 12. To aid in the

given as general
ordered health of the
patient.