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ASSESSMENT DIAGNOSIS PLANNIN

G

INTERVENTIO

N

RATIONALE EVALUATION

SUBJECTIVE:

Masakit gawa

ng may bakal,alo na kapag

malamig, kagayakagadi sobrang

akit

OBJECTIVES:

With steinmanspin at left knee

Pain Scale-7/10

BP- 130/80

mmHg

P- 104 bpm

rritable at times

Acute painrelated to

physicalinjuring

agents

At the endOf nursing

interventionand

collaborative medical

management, the patient

will reportthe pain is

reduce from7 out of 10

down to 4

out of 10

>Note client age/developmental

level & currentcondition

affecting ability

>Assess forreferred pain

>Obtain clientsassessment of

pain to include

location,characteristics,duration @

aggravatingfactors

>Accept client

description ofpain

>Monitor skincolor/ temp, V/S

>Provide

comfortmeasures like

repositioning

Provide/recom

mend nonpharmacological

measures thatreliefs of pain

e.g. quite dimlyroom, relaxation

techniques(guided imagery,destructing and

diversional

>To help determinethe possibility of

underlying conditions

>To report painparameter

>To rule outworsening of

underlying conditions

>Pain is a subjective

experience andcannot be felt by

others

>Usually altered inacute pain

>To promote non

pharmacological painmanagement

Measures that

reduce cerebralvascular pressure and

that slow sympatheticresponse and

effective in relievingheadache and

associatedcomplications

Goal met asevidence by:

The patient will

reported that thepain was lessen

With PS=4/10

BP=120/70mmHg

P- 91 bpm

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activities.

Administer

analgesic as

indicated to

maximumdosage asneeded.

To maintain

acceptable level of

pain. Notify

physician if regimenis inadequate to paincontrol goal.

SUBJECTIVE:

OBJECTIVES:

With openwound

With steinmans

pin at the rightdistal femur

With dry and

ntact dressing

Risk forinfection

related topresence of

steinmanspin inserted

at the rightdistal fmur

At the endof nursing

interventions, the patient

will identifyintervention

s to preventor reduce

risk forinfection

Verbalized

understanding of

individualcausative/ris

k factors

Observe for

localized signsof infection at

insertion site

Teach proper

hand washing

techniques topatients and

caregiver

Cleanse

incision site,change dressing

as needed

Encourage deep

breathingexercise,

coughing, andposition change

such as turningside to side

Give health

teachings suchas:

a. increasefluid

intake

To assess causative

or contributingfactors that may help

for furtherobservations and

management to

prevent infection

To reduce existing

risk factors, hand

washing is the firstline of defense

against infection

To prevent wound

contamination

For mobilization of

respiratory secretions

To maintain proper

hydration

At the end of thenursing

interventions, thepatient and his

care giver gainedknowledge and

how to preventinfection

The patientverbalized his

understandingand asked some

related questions

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SUBJECTIVE:

> Hindi ako

makakain ngmaayos wala ako

ganang kumain.

OBJECTIVES:

slightly thin in

appearance

with slightly

poor appetite

weight- 50 kg

Imbalanced

nutrition lessthan body

requirementsr/t loss of

appetite

At the end

of nursingintervention

patient willdemonstrate

behaviors,lifestyle

changes toregain or

maintainappropriate

weight.

> Assess weight

>Auscultatebowel sounds

>Evaluate totaldaily food intake

>Minimize

unpleasant odor

>Provide oral

care before andafter meals

>Promoteadequate/ timely

fluid intake

>Emphasize

importance ofwell-balanced

>daily weighing

provides data toevaluate nitrogen

balance

> certain conditionsand medications and

prolonged immobilitycan disturb G.I

function

> identify theneed formedications and

teaching

> unpleasant odor

effect negativeimpact to appetite

>poor oral hygiene

leads to bad odor andtaste, which can

diminish appetite

>these fluidrestriction help

prevent gastricdistention

>during illness, good

nutrition can reducethe risk of

complications andspeed recovery

Goal met as

evidenced by:

pt seen ingood

appetite

patientintake

food richin

nutrients

weight-46kg

SUBJECTIVE:

>Hindi akomakadumi

atlong araw napo.

OBJECTIVES:

with

Risk forconstipation

r/timmobilizati

on asevidenced by

decreaseperistaltic

movement

At the endof nursing

interventionpatient and

s.o willunderstand

thetechnique of

activeexercise

Explainedpassive and

active exercise

Auscultatedbowel sounds

Regular physicalactivity ais

elimination bimproving abdimonal

muscle tone andstimulating appetite

and peristalsis

Bowel soundsindicate the nature of

Seen patienteat high in

fiber foods Patient

stated thathe normally

lose hisbowel

movement Seen patient

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slightly

pale inconjunctiva

with drylips noted

Seen lyingon bed

frequently

withcomplaint

ofdifficulty

to defecate

abdominalmuscle

weakness

Promote exercise

program

Provide adequatefluid intake

necessary fortreatment

regimen

Advice to eatfoods such as

vegetables andfruits

Advice patient toeat food rich infiber

Administer stoolmild softener as

orderedDiscuss rationale

to encouragecontinuation of

successfulintervention

peristaltic activity

To encourage patient

help his status

Increase in fluidintake help to

softened stool

High fiber contentstimulates peristalsis

A sense of normalcyand familiarity can

help reduceembarrassment and

promote relaxationwhich may aid

defecation

eat high in

fiber foods Patient

stated thathe normally

lose hisbowel

movement