CROHN’S DISEASE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for  Client will  Assess the client’s ability,  Learning best occurs  Client asked
“Alam kong may ineffective demonstrate readiness to learn and when learners are questions related to
sakit ako, pero hindi therapeutic motivation to learn as previous knowledge r/t motivated and when the purpose of her
ko naman alam kung regimen measured by health preservation, instruction is medications, what
ano’ng nagagawa ng management verbalization of desire medication management, tailored to the they treated and
mga gamot na ‘yan related to and asking questions disease states and client’s cognitive expressed desire for
sa’kin.Hindi ko tuloy insufficient related to health on community resources. ability reference materials. 
malaman kung knowledge the end of the shift. Client also expressed
epektib ba ‘yan.” As concerning the  Assess personal context and  Providing desire to learn of
verbalized by the process and  Client will identify meaning of illness including interventions that community resources
client. management of perceived learning perceived changes in incorporate personal and ways to “not see
the disease needs as measured by lifestyle, financial concerns perspectives and the doctor.”
Objective: verbalization of at and impact on culture meaning of illness
Nonverbal behaviors least 2 topics on the results in improved  Client identified
indicate end of the shift. symptom learning needs as: 
attentiveness and management and medication
concern for  Client will understand client satisfaction information and
knowing. disease processes, management,
causes and factors  Provide information to  Educational community
contributing to support self-efficacy, self- programs based on resources, and
symptoms as regulation and self- empowerment have nutrition suggestions.
measured by management by focusing on demonstrated
verbalization of problem solving and effectiveness
knowledge after one decision making.   The client has
week. understood the basic
 Tailor the delivery of  Clients with lower disease process.
instruction to the client’s literacy benefit from
 Client will identify cognitive level by using well-tailored  Client has identified
medications used for visual aids (medication materials at least three of the
 symptom control of chart, brochures) and oral medications. 
each medical accessible word choices.
condition as measured
by verbalization of
accurate knowledge  Evaluate learning outcomes  Evaluation serves as
after one week. using patient verbalizations. an assessment of the
effectiveness of care
 Client will and allows
understand how to opportunity for
incorporate new adjustments to the
health regimens into plan of care
lifestyle measured by
verbalization of
knowledge after one
week.

 Client will
demonstrate
knowledge of
community resources
via verbalization after
one week.
  
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Imbalanced  At the end of  Weigh daily.  Provides  The client has
“Ang dami-dami na nutrition, less than the shift, the client information about showed interest in
ngang bawal, body requirements, will be able to dietary eating; he
naisusuka ko pa ‘yung related to dietary have a good needs/effectiveness verbalized food
mga kinakain ko.” As restrictions, nausea appetite as of therapy. requests
verbalized by the and vomiting manifested by appropriate to his
client. verbalization of  Encourage bedrest and/or  Decreasing proper diet.
proper foods to be limited activity during metabolic needs
Objective: eaten or showing acute phase of illness. aids in preventing  There is a
The client is weak- increased interest caloric depletion decreased
looking and has pale in eating. and conserves incidence of nausea
mucous membranes. energy. and vomiting.
 After 2 days of
nursing  Recommend rest before  Quiets peristalsis
intervention, meals. and increases
the client will available energy for
identify eating.
interventions
for nausea  Provide oral hygiene.  A clean mouth can
and vomiting enhance the taste of
and will report food.
decrease in
incidence of  Serve foods in well-  Pleasant
nausea and ventilated, pleasant environment aids in
vomiting surroundings, with reducing stress and
unhurried atmosphere, is more conducive
congenial company. to eating.

 Avoid/limit foods that  Individual

might cause/exacerbate tolerance varies,
abdominal cramping, depending on stage
 flatulence (e.g., milk of disease and area
products, foods high in of bowel affected.
fiber or fat, alcohol,
caffeinated beverages,
chocolate)

 Record intake and  Useful in

changes in identifying specific
symptomatology. deficiencies and
determining GI
response to foods.

 Promote patient  Provides sense of

participation in dietary control for patient
planning as possible. and opportunity to
select foods
desired/enjoyed,
which may increase
intake.

 Encourage patient to  Hesitation to eat

verbalize feelings may be result of
concerning resumption fear that food will
of diet cause exacerbation
of symptoms
APPENDICITIS

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain At the end of the shift,  Assess pain, noting  Useful in monitoring  The client has
“Masakit pa sa gawi related the client will be able location, effectiveness of medication, verbalized a
dito.”(while pointing to tissue to characteristics, progression of healing. decrease in the pain
at the right lower damage manifest ability to severity (0–10 scale). Changes in characteristics of he felt from 6/10 to
quadrant of the secondary to cope with Investigate and report pain may indicate 3/10
abdomen). As surgical incision incompletely changes in pain as developing
verbalized by the (appendectomy) relieved pain as appropriate. abscess/peritonitis, requiring  The client actively
client. The client also evidenced by prompt medical evaluation engaged in
verbalized 6/10 in the and intervention diversional
pain scale.  verbalization activities.
of decrease pain  Provide accurate,  Being informed about
Objective: form 6/10 to honest information to progress of situation  The client has
The client manifests 3/10 client. provides emotional support, reported improved
guarding behavior. helping to decrease anxiety sleep/rest.
The surgical site has  using relaxation
intact dressing. techniques or  Keep at rest in semi-  Gravity localizes
diversional Fowler’s position. inflammatory exudate into
activities such lower abdomen or pelvis,
as relieving abdominal tension,
socialization, which is accentuated by
watching TV, supine position.
and listening to
relaxing music  Encourage early  Promotes normalization of
ambulation. organ function, e.g.,
 ability to sleep stimulates peristalsis and
well or rest passing of flatus, reducing
appropriately abdominal discomfort.

 Provide diversional  Refocuses attention,

 activities. promotes relaxation, and
may enhance coping
abilities.

 Administer analgesics  Relief of pain facilitates

as indicated. cooperation with other
therapeutic interventions,

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for At the end of the shift,  Practice/instruct in  Reduces risk of spread of  .The client
“Mabilis lang naman infection the client will: good handwashing bacteria. displayed
siguro ‘tong gagaling
related to  verbalize ways and aseptic wound knowledge on
kung hindi magkaka- tissue trauma on care. wound care.
komplikasyon”. As preventing
verbalized by the infection  Inspect incision and  Provides for early detection  The client’s vital
client. specifically dressings. Note of developing infectious signs remained
proper hand characteristics of process, and/or monitors stable
Objective: washing, and drainage from resolution of preexisting
The client has dry, proper wound wound/drains (if peritonitis.  The client has good
intact dressing on care inserted), presence of skin integrity with
the surgical site. erythema. decreased swelling.
 maintain stable
vital signs  Monitor vital signs.  Suggestive of presence of
Note onset of fever, infection/developing sepsis,
 have good skin chills, diaphoresis, abscess, peritonitis
integrity changes in mentation,
reports of increasing
 manifest abdominal pain.
decrease in
swelling/pain on  Obtain drainage  Gram’s stain, culture, and
surgical site specimens if sensitivity testing isuseful in
indicated. identifying causative
organism and choice of
therapy.

 Administer antibiotics  Antibiotics given before

as appropriate appendectomy are primarily
for prophylaxis of wound
infection and are not
continued postoperatively.
Therapeutic antibiotics are
administered if the appendix
is ruptured/abscessed or
peritonitis has developed.
ULCERATIVE COLITIS

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: “Limang Diarrhea related At the end of two shifts,  Observe and  Helps differentiate  After two shifts, the
beses na akong to the client will: record stool individual disease and client reported relief
nadumi ngayong inflammation/m  report a decrease in frequency, assesses severity of of the discomfort of
araw, ‘yung iba may albasorption of frequency of characteristics, and episode. having diarrhea.
dugo.” As verbalized the bowel stools amount
by the client  Avoiding intestinal
 have a close-to-normal  Identify foods irritants promotes
Objective: consistency of stool and fluids that intestinal rest.
Hyperactive bowel precipitate
sounds diarrhea

 Monitor intake and  Provides information

output. about overall fluid
balance, renal function,
and bowel disease control,
as well as guidelines for
fluid replacement.

 Observe for signs of  Indicates excessive fluid

dehydration, such as loss.
excessively dry skin
and mucous
membranes,
decreased skin
turgor.

 Administer parenteral  Maintenance of bowel rest

fluids, requires alternative fluid
as indicated. replacement to
 correct
losses/anemia.

 Monitor laboratory  Determines

studies, e.g., replacement needs
electrolytes and and effectiveness
ABGs. of therapy

 Administer  Reduces fluid losses

medications as from intestines.
indicate.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for At the end of two shifts,  Inspect  Monitors healing  Before the end of
“Baka mamaga o impaired tissue the client will: stoma/peristomal skin process/effectiveness of two shifts, the
maimpeksyon ‘tong integrity related area with each pouch appliances and identifies client
binutas sa’kin ”as to drainage  Maintain skin change. Note irritation, areas of concern, need for demonstrated
verbalized by the from temporary integrity around bruises (dark, bluish further behaviors that
client. ileostomy stoma color), rashes. evaluation/intervention. prevents skin
 .Identify breakdown.
Objective: individual risk  Clean with warm water
Changes in factors. and pat dry. Use soap  Maintaining a clean/dry area
pigmentation  Demonstrate only if area is covered helps prevent skin
Prescence of edema behaviors/techniq with sticky stool. If breakdown.
ues to promote paste has collected on
healing/prevent the skin, let it dry, then
skin breakdown. peel it off.

 Measure stoma
periodically, e.g., at
least weekly for first 6  As postoperative edema
 wk, then once a month resolves (during first 6 wk),
for 6 mo. Measure both the stoma shrinks and size of
width and length of appliance must be altered to
stoma.Verify that ensure proper fit so that
opening on adhesive effluent is collected as it
backing of pouch is at flows from the ostomy and
least 1⁄16 to contact with the skin is
prevented.
 1⁄8 in (2–3 mm) larger
than the base of the
stoma, with adequate  Prevents trauma to the stoma
adhesiveness left to tissue and protects the
apply pouch. peristomal skin. Adequate
adhesive area prevents the
skin barrier wafer from being
too tight. Note:Too tight a fit
may cause stomal edema or
 Use a transparent, stenosis.
odor-proof drainable
pouch.  A transparent appliance
during first 4–6 wk allows
easy observation of stoma
without necessity of
removing pouch/irritating
 Apply appropriate skin skin.
barrier, e.g.,
hydrocolloid wafer,  Protects skin from pouch
karaya gun, extended- adhesive, enhances
wear skin barrier, or adhesiveness of pouch, and
similar products. facilitates removal of pouch
when necessary.
 Empty, irrigate, and
cleanse ostomy pouch
 on a routine basis,  .Frequent pouch changes are
using appropriate irritating to the skin and
equipment. should be avoided. Emptying
and rinsing the pouch with
the proper solution not only
removes bacteria and odor-
causing stool and flatus but
also deodorizes the pouch.
 Support surrounding
skin when gently  Prevents tissue
removing appliance. irritation/destruction
Apply adhesive associated with “pulling”
removers as indicated, pouch off.
then wash thoroughly.

 Investigate reports of
burning/itching/blisteri  Indicative of effluent leakage
ng around stoma. with peristomal irritation, or
possibly Candida infection,
requiring intervention.
.
 Apply corticosteroid  Assists in healing if
aerosol spray and peristomal irritation
prescribed antifungal persists/fungal infection
powder as indicated. develops.Note:These
products can have potent side
effects and should be used
sparingly..