NURSING GOAL NURSING INTERVENTION WITH EVALUATION

DIAGNOSIS RATIONALE
Risk for deficient Patient will 1.Assess and document colour, The patient able to
fluid volume as maintain amount and characteristic of maintain adequate
evidenced by adequate fluid vomitus. fluid and free from
vomiting. and free from Rationale : Determine fluid vomiting.
vomiting. replacement.

2.Maintain accurate record of

input and output chart.
Rationale : To provide
information about fluid status and
circulating volume needing
replacement.

3.Monitor for sign and symptom

of vomiting.
Rationale : Prolonged vomiting
can lead to deficits in sodium,
potassium and chloride.

4.Urge the patient to drink

prescribed amount of fluid.
Rationale : Oral fluid replacement
is indicated for mild fluid deficit
and is a cost-effective method for
replacement treatment.

5.Emphasize importance of oral

hygiene.
Rationale : Fluid deficit can cause
a dry, sticky mouth.

6.Eliminate noxious sights or

smells from environment.
Rationale : To reduces stimulation
of vomiting center.

7.Administer antiemetics and

antidiarrheals as doctor ordered.
Rationale : To prevent further
fluid loss.

Deficient Patient will able 1.Assess motivation and Patient able to

knowledge about to explain willingness of patient to learn. explain disease
prognosis and disease state, Rationale : Learning requires state, recognizes
treatment needs recognizes need energy. Patient must see a need need for
related to for medication or purpose for learning. medication and
information and well understanding
misinterpretation. understanding 2.Allow the patient to open up treatment
treatment. about previous experience and
health teaching.
Rationale : Patient learn best
when teaching builds on previous
knowledge and experience.

3.Observe and note existing

misconceptions regarding
material to be taught.
Rationale : Assessment provides
an important starting point in
education. Knowledge serves to
correct faulty ideas.

4.Provide clear and

understandable explanation.
Rationale : Patient is better able
to ask questions when they have
basic information about what to
expect.

5.Provide the important

explanation regarding
medications and treatment needs.
Rationale : To allow patient to
identify and know the most
significant content.

6.Encourage questions.
Rationale : To make the patient
more understand about the topic
that have been discussed.

7.Help patient in integrating

information into daily life.
Rationale : This technique aids
the learner make adjustments in
daily life that will result in the
desired change in behaviour.

Acute pain related After the nursing 1.To observe and document location, Patient pain is
to inflammatory intervention, severity (0–10 scale), and character reduced
process as evidence patient pain will of pain.
by report of pain. be reduce Rationale : To assists in
differentiating cause of pain, and
provides information about disease
resolution.

2.To promote bed rest, allowing

patient to assume position of
comfort.
Rationale : To bed rest in low-
Fowler’s position reduces intra-
abdominal pressure.

3.To control environmental

temperature.
Rationale : To cool surroundings aid
in minimizing dermal discomfort.

4.To encourage use of relaxation

techniques and provide diversional
activities.
Rationale : To promotes rest and
redirects attention, may enhance
coping.

5.To Use soft or cotton linens,

calamine lotion, oil bath and cool
compresses as indicated
Rationale : To reduces irritation or
dryness of the skin and itching
sensation.

6. To note response to medication,

and report to physician if pain is not
being relieved.
Rationale : To severe pain not
relieved by routine measures may
indicate developing complications or
need for further intervention.

7.To make time to listen to and

maintain frequent contact with
patient.
Rationale : To helpful in alleviating
anxiety and refocusing attention,
which can relieve pain.

Ineffective breath Patient will be 1.To observe respiratory rate and Patient able to
pattern related to establish depth. establish effective
pain as evidence by effective Rationale : To observe shallow breathing pattern
holding breath breathing breathing, splinting with respirations,
reluctance to pattern. holding breath may result in
cough. hypoventilation.

2.To auscultate breath sounds.

Rationale : To identify areas of
decreased or absent breath sounds
suggest hypoventilation, whereas
adventitious sound.

3.To assist patient to turn, cough,

and deep breathe periodically.
Rationale : To promotes ventilation
of all lung segments and mobilization
and expectoration of secretions.

4.To instruct effective breathing

techniques.
Rationale : To provides incisional
support and decreases muscle
tension.

5.To elevate the head of bed,

maintain low-Fowler’s position.
Rationale : To maximizes expansion
of lungs to prevent or resolve
hypoventilation.

6.To support abdomen when

coughing and ambulating.
Rationale : To facilitates more
effective coughing, deep breathing,
and activity.

7.To make time to listen to with

patient.
Rationale : To helpful in alleviating
anxiety and refocusing attention.

Insomnia related After nursing 1. Encourage participation in Patient was able to

to shoulder pain intervention, regular exercise during daytime sleep 5-8 hours per
patient will be Rationale : To release energy. night
 able to develop However, exercise in bedtime may
uninterrupted stimulate rather than relax the
sleep pattern 5- body
8 hours per
night. 2.Limit fluid intake in the evening
Rationale : To reduce need for
night time elimination.

3. Develop a sleep relaxation with

client
Rationale : Employing both
physical and mental relaxation
can help minimize anxiety and
promote sleep.

4. Promote comfort to patient

such as give them blanket and tidy
up their bed.
Rationale : To feel more
comfortable and relax .

5.Provide good temperature in

the room
Rationale : Patient will feel more
calm and feel more comfortable

6. Instruct patient to do deep

breathing exercise
Rationale : Help to reduce the
pain and feel more comfortable
and relax

7. Provide a properly positioned

towards the patient
Rationale : Properly position will
help and promote comfort to
patient.

Fever related to After nursing 1. Check temperature 4 hourly Patient’s body

disease as intervention, Rationale : To informed and temperature
evidence by the patient’s notice patient’s temperature has maintain 37 to
temperature 39 ° temperature been reduce and to prevent from 36.8 °c
c will be reduce further complication
to 36.5 to 37°c
2. Do tepid sponging to patient
Rationale : Help and manage to
reduce the temperature and
provide coolness towards patient

3. Recheck temperature after 30

minutes
Rationale : To ensure that
patient’s body temperature
regulate to normal range

4. Tranfuse I/V fluid as ordered if

not taking sufficient oral fluids
Rationale : To make sure patient
will not being dehydrated because
of lack of fluids in the body

5. Wear light and loose clothing

for patient
Rationale : To feel more
comfortable

6. Switch on fan and provide good

temperature of environment
Rationale: To make patient feel
calm and coolness and manage to
help reduce patient temperature

7. Administer antipyretics as
ordered by doctor
Rationale : Help to reduce fever