8/4/2019 ncp rsi
1/3
Assessment Diagnosis Planning Intervention Rationale
Evaluation
Subjective:Hirap akomaglakad kasinga namamagayung mga paa kopati
ang mgakamay ko kayamadalasnakahiga na langako dito sahigaan.
Asverbalized by thepatient.
Objective: Edema on bothupper and lowerextremities.
LowHemoglobincount.
Fever with
temperature of39 degreesCelsius
ActivityIntolerancerelated toinflammatoryprocess asmanifested
byedema on bothupper and lowerextremities.
After 8 hours ofNursingIntervention thepatient will beable
to:
Objective: Identifytechniques thatwould
enhanceactivityintolerance.
Participatewillingly innecessary anddesired activities
Goal: Promoteactivities that thepatient can do
Maintain qualityof life.
Establish rapport
Provide cool andcleanenvironment
Monitor patientsinput and output
Encourage thepatient toverbalize herfeelings
Give clientinformation abouther progress
Assist client in hisdaily needs
To have a bettercooperation fromthe patient.
To promote restperiods.
To know if thereis an increase inoutput ratherthan in input.
To be able theexpress and saywhat she wantedto say regardingher
illness.
To promotemotivation
This is topromote personal
hygiene andother things thatthe patientneeded to do.
After 8 hours ofNursingIntervention thepatient was ableto:
Identifytechniques thatwould enhanceactivityintolerance.
Yes __ No __
Participatewillingly innecessary anddesired activities
Yes __ No __
8/4/2019 ncp rsi
2/3
Assessment Diagnosis Planning Intervention Rationale
Evaluation
Subjective: Bago pa akomaadmit dito saospital ehnanghihina naako
kahithanggangngayon ehnanghihina padin ako. Asverbalized by
thepatient.
Objective: General BodyWeakness.
Edema on bothupper and lowerextremities.
Temperature of39 degreesCelsius.
Difficultystanding or evensitting in the bed.
Risk for falls. After 8 hours of NursingIntervention thepatient
will beable to:
Objective: Verbalizeunderstanding ofindividual riskfactors that
maycontribute toinjuries.
Prevent thepossibleoccurrence ofinjury.
Modify herenvironment asindicated toenhance safety.
Establish rapport
Provide cool andcleanenvironment
Encourage thepatient toverbalize hisneeds
As much aspossible alwaysraise the bedsside rails of
thepatient.
When the patientwill urinateadvise her to usebedpan.
Advise thepatient to alwaysask assistancewith her relativesor if
the relativesis not accessiblethen with thenurse on duty orstudent
nurse.
To have a bettercooperation fromthe patient.
To promote restperiods.
To expect whatare the possiblethings needed todo for
thepatient.
To prevent fallsand injuries
To prevent fallsand injuries
To prevent fallsand injuries
After 8 hours ofNursingIntervention thepatient was ableto:
Verbalizeunderstanding ofindividual riskfactors that
maycontribute toinjuries.
Yes __ No __
Prevent thepossibleoccurrence ofinjury
Yes __ No __
Modify herenvironment as
indicated toenhance safety
Yes __ No __
