Patient’s Name: Angkad, Meriam P. Hospital No.

: 00195723
Age: 52y.o. Diagnosis: Respiratory Tract Infection CAP-MR
Room No.:106 Attending Physician:M-Liway F. Miranda, M.D.
Student/Placement: Charles Philip A. Gonzales/NS1 Date: 10/24/23

ASSESSMENT NSG. DIAGNOSIS OBJECTIVE OF NURSING RATIONALE EVALUATION

W/SCIENTIFIC CARE INTERVENTION
BASIS
S: “Putol-putol po tulog Disturbed sleeping After 3 hours of Independent: After 3 hours of
tapos luya akong patterns related to nursing interventions, Establish rapport To create a good nurse nursing interventions,
panglawas” as environmental barrier the patient will be able patient relationship and the patient was be able
verbalized by the patient as evidenced by to verbalize on how to develop trust to verbalize on how to
restlessness and body manage and cope or manage and cope or
weakness achieve optimal Take and record vital Provide as baseline achieve optimal
amount of sleep signs data amount of sleep

Assess sleep pattern High percentage of GOAL MET

disturbances that are sleep disturbances can
associated with the affect the recovery of
environment the patient

Observe and obtain To provide basis of

feedbacks regarding on coping strategy
O: the usual sleeping formulation
 Body weakness pattern, bedtime
 Restless routine and the usual
 Minimized number of hours of
movements sleep and rest
 Agitated
 Taking a nap Develop or device a To address the
when there is a coping strategy on how underlying cause of the
chance to do so. to manage sleep and patient’s disturbed
sleeping patterns patterns of sleep
 Dependent:
Administer To address other
medications as underlying cause of the
prescribed patient’s medical
condition
NEEDS:
In addressing the needs
of the patient reported
that she is unable to have
a good rest or sleep and
is interrupted often by
the environment she is
in, the patient likely is in
need of sleep considered
to be one of the basic
necessities of any human
being and is crucial for
the recovery of the
patient under the
physiological needs of
Maslow’s theory.
Patient’s Name: Ranada, Mark Dave E. Hospital No. : 000014127
Age: 20y.o. Diagnosis: Tension Headache
Room No.: 106 Attending Physician: M-Liway F. Miranda, M.D.
Student/Placement: Charles Philip A. Gonzales/NS1 Date: 10/24/23

ASSESSMENT NSG. DIAGNOSIS OBJECTIVE OF NURSING RATIONALE EVALUATION

W/SCIENTIFIC CARE INTERVENTION
BASIS
S: “Naga sakit akong Impaired comfort After 4 hours of Independent: After 4hrs of nursing
ulo” as verbalized by the related to headache nursing interventions, Establish rapport to the To create a good nurse interventions, the
patient the patient’s condition patient. patient relationship and patient’s condition of
of altered comfort and develop trust altered comfort and
pain will be decreased pain was decreased and
and patient will Take and record vital Provide as baseline patient verbalized
verbalize relief of mild signs data relief of mild to
to moderate pain of 3 moderate pain of 3 to a
to a diminished amount Note for the location, To determine the diminished amount in
in scale scale, intensity and nursing care to be scale
onset of pain. given to the patient.
GOAL MET
Use relaxation To promote comfort
technique such as: and relaxation.
O: deep breathing
 Pain Scale of exercise
3/10
 Body weakness Encourage complete To reduce the
and restlessness bed rest metabolic demand of
the body, thus
improving healing and
recovery

Dependent:
 Administer prescribed To address pain
medications

NEEDS:
The patient was
experiencing a headache
maybe or possibly due to
a previous head injury.
The patient is in need of
rest and sleep to address
his restlessness and body
weakness which is under
the physiological needs
of Maslow’s theory. The
patient also is in need for
his family and friends as
his condition is as
serious as any other
illnesses or diseases mild
or severe he needs love
and belonging through
his family and friends.