ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for Grieving Short-term: Treat the patient with To build nurse- After 2-4 hours of
related to loss of After 2-4 hours of respect, give her the patient relationship. nursing intervention
“Nalulungkot ako sa fetus associated by nursing intervention opportunity to talk the patient expresses
pagkawala ng anak lack of sleep and the patient will be about concerns, and her sorrow in losing
ko. At mas nagaalala disorganization able to express and answer questions her child and realizes
ko kasi ako ang sinisisi manifest her sorrow honestly. that the emotions
ng mister ko” in losing her child and she’s experiencing is
will realize that the just normal.
Objective: emotions that she is Listen to the patient’s The most effective
experiencing is just expression of grief. way of
BP: normal. communication is
120/80 active listening
Respiratory Rate:
19 cpm
Temperature: Long-term: Help the patient to One effective way of After 2 days of
36.6 After 2 days of determine sources of coping mechanism is nursing intervention
Pain Scale: nursing intervention support and how to having a person who the patient slowly
4/10 the patient will slowly use them effectively. will be there for you. accepting the reality
Pulse Rate: accept reality and A confidant for that she lost her
80 bpm loss of her child. instance. child.

Focus on enhancing To be more specific

the individual coping and implement
skills of the person’s needed intervention
grieving to alleviate accurately
life problems and
distressing
symptoms.
Reassure patient and Concern about how
significant others that others may view one’
some negative full range of feelings
thoughts and feelings may lead to further
are normal. impediments in
grieving process and
increase a sense of
isolation and loss.

Encourage the family A person who is

to follow comforting grieving needs a solid
grief rituals such as support system
interacting with
nature, saying a
praying or whatever
ritual brings spiritual
comfort in dealing
with the loss

Encourage sharing of Venting out helps in

common problems relieving negative
with others. thoughts.

Collaborative:

Encourage parents to
seek mental health
services as needed,
learn stress
reduction, and take
good care of their
health.

Explain that Reassuring the

emotional response patient may aid in
to loss is appropriate coping up.
and commonly
experienced (denial,
anger, bargaining,
depression,
acceptance)
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute Pain related to Short-term: Determine the Although some After 3 hours of
Masakit po ang aking surgical intervention After 3 hours of extent/severity and discomfort is nursing intervention
pwerta ilang araw specifically D&C as nursing intervention location of discomfort expected, severe the patient stated
pagakatapos kong manifested by facial the patient will be cramping and that discomfort is
iraspa” grimace and able to state that abdominal minimized or
utterance of pain discomfort is tenderness may controlled.
minimized or indicate
controlled complications
Objective:
BP: Explain to the client Knowledge helps the
120/80 Long term: the nature of client to cope with
Respiratory Rate: After 1-2 days of discomfort expected reality After 1-2 days of
19 cpm nursing intervention nursing intervention
Temperature: the patient will be the patient performs
36.6 able to perform Provide comfort Proper breathing activities of recovery
Pain Scale: activities of recovery measures such as technique can help such as walking or
4/10 such as walking or relaxation and the patient reduce ADLs easily.
Pulse Rate: ADLs easily breathing techniques the pain.
80 bpm

Provide rest periods A quiet environment,

to facilitate comfort, a darkened room, and
sleep, and relaxation. a disconnected phone
are all measures
geared toward
facilitating rest.
 Eliminate additional A patient with a
stressors or sources stress free
of discomfort environment will
whenever possible. lessen the pain.

Dependent:
Administer These drugs promote
narcotic/nonnarcotic relaxation, decrease
analgesics, sedatives, pain, and control side
and antiemetic as effects of treatment
prescribed by
physician

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 This allows patient to
Subjective: Deficient knowledge Short-term: Provide physical concentrate on what
“hindi ko po alam na related to abortion as After 3 hours of comfort for learner is being discussed
nakunan na ako, evidence by nursing intervention
akala ko dinugo ako unfamiliarity with the the patient will be Provide a quiet This allows patient to
dahil sa UTI lang” condition and able to recognize the atmosphere without concentrate more
statement of disease state. interruption completely
misconception
Provide an This allows the
Objective: Long term: atmosphere of patient to be more
BP: After 2 days of respect, openness, comfortable and
120/80 nursing intervention trust, and promote rapport
Respiratory Rate: the patient will be collaboration
19 cpm able to understand
Temperature: the disease state and Establish objectives This allows learner to
36.6 to know health and goals for learning know what will be
Pain Scale: regimens to prevent at the beginning of discussed and
4/10 the occurrence of the session expected during the
Pulse Rate: such condition session. Adults tend
80 bpm to focus on here-and-
now

Explore attitudes and This assist the nurse

cultural beliefs and in understanding how
feelings about the learner may respond
existing condition to the information
and possibly how
compliant patient
may be with the
expected changes

Discuss and provide This allows the

information about patient to know when
probable signs of to call or to reach for
 abortions and her health care
predisposing factors provider

Give clear, thorough

explanations and
demonstrations

Provide information Different people take

using various in information in
mediums (e.g., different ways
explanations,
discussions,
demonstrations,
pictures, written
instructions, and
videotapes)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Anxiety related to Short-term:
“Natakot nakong recent occurrence of After 2-3 hours of
magbudus ta tibad abortion as evidenced nursing intervention
malaglagan nanaman by verbalization of the patient will
ako” possible reoccurrence
of the condition

Objective:

BP:
120/80
Respiratory Rate:
19 cpm
Temperature:
36.6
Pain Scale:
4/10
Pulse Rate:
80 bpm