Assessment Nursing Goals Interventions Rationale Evaluation

Diagnosis
Subjective: Disturbed sleep Short Term Independent Short Term :
“di ako pattern related After 3 hours of nursing • Position client in a • To alleviate discomfort After 3 hours of nursing
makatulog kasi to discomfort on intervention, the client comfortable position intervention, the short term
puro na lang perineum as will: goal was met as evidenced by:
sakit sa katawan manifested by • report decreased • Provide comfort • To distract attention on • Reported pain relief (5
yung verbal reports. feeling of discomfort as measures (touch, quiet pain, reduce tension and out of 10)
nararamdaman manifested by environment, dim to promote
ko” verbalizing feeling of light, light music) nonpharmacological pain
As verbalized by comfort (5 out of 10) management Long Term
the client After 3 days of nursing
Long Term • Provide a quiet and • To help in providing intervention the short term goal
Objective: After 3 days of nursing peaceful environment better sleep/rest has been fully met as evidenced
• 1hr of sleep intervention the client during sleep periods by:
per day PTA will: • reported increased
• 30 mins of • Be able to • Encourage the client • Verbalizing concerns may periods of sleep of 8
sleep per reestablish and to express concerns promote relaxation continuous hours per day
day upon maintain normal sleep when unable to sleep
admission pattern • absence of frequent
• frequent • achieve 7-8 hours • Provide a warm bath • Vasodilation of the veins yawning
yawning at of continuous sleep before the client goes provide a sleepy, lazy
daytime per day to sleep effect, causing the client to • established sleep pattern
during • report absence of fall right to sleep
assessment body malaise • reported pain scale of 3
• dark circles • report further • Expose perineum on • To provide comfort out of 10
around the alleviation of pain (3 perilight bid for 15
eyes out of 10) mins • reported absence of body
V/S: • absence of COLLABORATIVE: • To induce sleep malaise
• BP- 90/60 frequent yawning • Prescribe sedatives
mmHg (Valium) as ordered
• RR- 26
cpm
• PR- 88
bpm
• Temp.:
37.3