8/11/2019 3NCP

1/4

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONSMay NGT ako tapos naka

connect pa ditto yung

isang fecal drainage ang

hirap sa pakiramdam as

verbalized by the client.

O> Alert, conscious,coherent

>Afebrile

>Oriented to time, place

and person

>Dry &poor skin turgor

>Capillary refill after 2-3

seconds

>Muscle strength of 5/5

on both upper and lower

extremities.

>weight loss (160 lbs-120

lbs within 6 months)

>NGT-Fecal drainage,

blood streaked stool (10-

20ml)

>Auscultated 5-6

borborygmic sound in

each quadrant for 1

minute.Tympany heard @

each quadrant

>V/S taken as follows: BP:

130/80,HR:78,RR:20,T:36

Impaired bowel

incontinence r/t

incomplete emptying

of bowel

SHORT-TERM:

After 8 hours of

nursing intervention,the client will be able

to verbalize

understanding of

causative

LONG-TERM:

After 3 days of

nursing intervention,

the client will be able

to identifyindividually

appropriate

interventions

INDEPENDENT:

>Established rapport and

Assessed general

condition

>Assessed historical

aspects of incontinence

with precipitating events

>Auscultated & palpated

abdomen

>Noted stoolcharacteristics (color,

odor, consistency,

amount,

shape, and frequency)

DEPENDENT:

>Administered

medications(enemas,

laxatives,etc.) as

prescribed by the doctor

COLLABORATIVE:

>Reviewed results of

diagnostic studies and

laboratory

>To gain trust and baseline

data

>To identify the most

common factors in

incontinence

>To determined for

presence, location, and

characteristics

of bowel sounds & any

distention, masses,

tenderness

>Provides comparativebaseline.

>To relief client for any

discomfort

> To identify for

abnormality in the values.

SHORT-TERM:

After 8 hours of

nursing intervention,the client was able to

verbalized

understanding of

causative

LONG-TERM:

After 3 days of

nursing intervention,

the client was able to

identified individuallyappropriate

interventions

8/11/2019 3NCP

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONSMalaki na rin ang

binagsak ng timbang ko

kumpara dati kase di nako

nakakakain ng maayos

dahil na rin sa kundisyonko as verbalized by the

client.

O> Alert, conscious,coherent

>Afebrile

>Oriented to time, place

and person

>Dry &poor skin turgor

>Capillary refill after 2-3

seconds

>Muscle strength of 5/5

on both upper and lower

extremities.

>weight loss (160 lbs-120

lbs within 6 months)

>NGT-Fecal drainage,

blood streaked stool (10-20ml)

>Auscultated 5-6

borborygmic sound in

each quadrant for 1

minute.Tympany heard @

each quadrant

>V/S taken as follows: BP:

130/80,HR:78,RR:20,T:36

Disturbed body image

r/t illness

SHORT-TERM:

After 8 hours of

nursing intervention,the client will be able

to verbalize

understanding of

body changes

LONG-TERM:

After 3 days of

nursing intervention,

the client will be ableto recognize and

incorporate body

image change into

self-concept in

accurate manner

without negating self-

esteem

INDEPENDENT:

>Established therapeutic

nurse-client relationship,

conveying anattitude of caring

>Assessed mental/physical

influence of condition on

the clients emotional

state

>Assessed clients current

level of adaptation and

progress

>Listen to clients

comments and responsesto the situation

>Encouraged positive

reinforcement

>Encouraged verbalization

of feelings

COLLABORATIVE:

>Used appropriate

communication

techniques

>Referred to appropriate

support groups.

>To establish trust and

baseline data

>To evaluate level of

clients knowledge &

anxiety related to situation

>To enhance acceptance

>To provide opportunities

for listening of concernsand questions

>To continue to strive for

improvement

>To decreased level of

anxiety

>To gain accurate

information

>To enhance more of the

knowledge

SHORT-TERM:

After 8 hours of

nursing intervention,the client was able to

verbalized

understanding of

body changes

LONG-TERM:

After 3 days of

nursing intervention,

the client was able torecognized and

incorporate body

image change into

self-concept in

accurate manner

without negating self-

esteem

8/11/2019 3NCP

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONSMalaki na rin ang

binagsak ng timbang ko

kumpara dati kase di nako

nakakakain ng maayos

dahil na rin sa kundisyonko as verbalized by the

client.

O> Alert, conscious,coherent

>Afebrile

>Oriented to time, place

and person

>Dry &poor skin turgor

>Capillary refill after 2-3

seconds

>Muscle strength of 5/5

on both upper and lower

extremities.

>weight loss (160 lbs-120

lbs within 6 months)

>NGT-Fecal drainage,

blood streaked stool (10-20ml)

>Auscultated 5-6

borborygmic sound in

each quadrant for 1

minute.Tympany heard @

each quadrant

>V/S taken as follows: BP:

130/80,HR:78,RR:20,T:36

Risk for infection r/t

increased exposure to

environmental

exposure to

pathogens

SHORT-TERM:

After 8 hours of

nursing intervention,

the client will be able

to prevent or reduce

the risk of infection

such as fever,

inflammation, loss of

function, and redness

LONG-TERM:

After 3 days of

nursing intervention,the client will be able

to demonstrate

techniques, lifestyle

changes to promote

safe environment.

INDEPENDENT:

>Established rapport and

Assessed general

condition

>Noted risk factors for

occurrence of infection

>Observed for localized

signs of infection at

insertion sites. Assess and

document skin conditions

around insertions of

drainage. Maintained

aseptic technique

> Encourage earlyambulation, deep

breathing, coughing,

position changes Q2

>Encouraged proper hand

washing

DEPENDENT:

>Administered

medications (antibiotics,

antivirals,etc.) as

prescribed by the doctors

COLLABORATIVE:

> Emphasized necessity of

PPE for all health care

team

>To gain trust and baseline

data

>To identify the source of

infection

> To decrease the risk of

further infection

>To promote mobilizationand prevention of

respiratory infection

>To eliminate the in

invading microorganisms

>To prevent occurring of

infection

>To fight the first-line

defense against

healthcare-associated

infections

SHORT-TERM:

After 8 hours of

nursing intervention,

the client was able to

prevent or reduce the

risk of infection such

as fever,

inflammation, loss of

function, and redness

LONG-TERM:

After 3 days ofnursing intervention,

the client was able to

demonstrated

techniques, lifestyle

changes to promote

safe environment

8/11/2019 3NCP

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