Guerrero, Precious Leanellie U.

N3-7 Grp. 26

Patient: Abad, Hermie

Problem: Upper Gastro Intestinal Bleeding

ASSESSMENT NURSING PATHOLOGY- PLANNING INTERVENTION SCIENTIFIC EVALUATION

DIAGNOSIS PHYSIOLOGY RATIONALE

Subjective: Deficient fluid Bactrial infection of Within 8 hours of 1. Maintain accurate 1. Provide information
After 8 hours of
volume related H. Pylori nursing record of Intake and about fluid
nursing
"Medyo madalas to loss of fluid ↓ interventions the Output. Assess status/circulating
interventios the
ako mauhaw at through Inflammatory patient will skin/mucous volume and
patient maintained
medyo nanghihina abnormal cascade initiated maintain fluid membrane and replacement need fluid volume at
ako" as verbalized route(Upper ↓ volume at peripheral pulses functional level as
by the patient Gastro Mucosal damage and functional level as evidenced by moist
Intestinal Ulceration evidenced by 2. Perform frequent 2. Decrease dryness mucous membrane
Objective: Bleeding) moist mucous oral hygiene of oral mucous and good skin
membrane and membrane turgor
-Vital signs taken good skin turgor
as follows: BP 3. Encourage fluid 3. Relieves thirst and
130/90 Temp. intake and promote discomfort of dry
36.2oc CR- 64 RR- intake of high water mucous membrane
20 content foods
-pallor
-body weakness 4. limit fluids that 4. To prevent further
Poor skin turgor, tends to exert a fluid loss
dry skin diuretic effect(e.g.,
-dry mouth alcohol, caffeine)

5. Administer 5. To deliver fluids

Intravenous Fluid as accurately and at
prescribed desired rates
Guerrero, Precious Leanellie U.
N3-7 Grp. 26

Patient: Abad, Hermie

Problem: Anxiety
 ASSESSMENT NURSING PLANNING INTERVENTION SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE

Subjective: Anxiety related Within 8 hours of 1. Monitor vital 1. To identify physical

After 8 hours of
to threat to/ or nursing signs(e.g., rapid or responses associatednursing
"hindi ko alam change in interventions the irregular pulse, rapid with both medical and
interventios the
kung health status patient will appear breathing) emotional conditionspatient appeared
makakapagtrabaho relaxed and the relaxed and the
na ako kaagad level of anxiety will 2. Use presence, 2. Being supportive level of anxiety will
pagkagaling ko eh" reduced to a touch, verbalization and approachable reduced to a
as verbalized by manageable level or demeanor to encourages manageable level
the patient remind client and to communication
encourage
Objective: expressions or
clarification of
- Vital signs taken needs, concerns,
as follows: BP unknowns and
130/90 Temp. questions
36.2oc CR- 64 RR-
20 3. Accept client's 3. If defenses are not
-restlessness defenses, do not threatened, the client
-difficulty in confront, argue and may feel safe enough
sleeping debate to look at the behavior
-fatigue
4. Allow and 4. Talking or
reinforce clients otherwise expressing
personal reaction feeling reduces
towards the anxiety
threatens to well
being

5. Explain 5. To educate the

everything patient regarding the
necessary regarding disease to reduce
the disease anxiety