ASSESSMENT NURSING OUTCOME PLANNED RATIONALE EVALUATION

DIAGNOSIS IDENTIFICATION INTERVENTION

S: “Masakit ang ulo at Acute Pain r/t Present S.T.O : Dx: S.T.O :
tiyan niya” as verbalized Illness  After 24 hrs of  Assessed general  To determine any  After 24 hrs of
by the watcher nursing health status underlying nursing
intervention the abnormalities intervention the
O: patient will  Monitored and  To have a baseline patient will be
 NGT intact verbalized relief of recorded v/s data able to verbalized
 weak body anxiety and body Tx: relief of anxiety
movement weakness.  Established  To gain and body
 limited body  After 24 hrs of Rapport cooperation and weakness.
movement nursing trust with the pt.  After 24 hrs of
 irritable intervention the  Ensured safety and  To help client nursing
 anxiety patient will comfort measures achieve OLOF intervention the
 warm skin to demonstrate use of patient will be able
touch relaxational  Encouraged  To prevent fatigue to demonstrate use
 afebrile 36.0 activities as adequate rest of relaxational
 occational indicated for period activities as
productive cough individual  Encouraged  To evaluate clients indicated for
situation verbalization of status. individual
L.T.O: feelings and situation
 After 3 days of concerns L.T.O:
nursing  Evaluated ability  To determine the  After 3 days of
intervention the to understand clients ability to nursing
patient will events, provided recognize present intervention the
incorporate realistic appraisal. status. patient will be able
therapeutic  Encouraged client  To help patient to incorporate
regimen into to use affirmation manage/ lessen therapeutic
activities of daily “ I am healing, pain regimen into
living (ADL) I am relaxed” psychologically activities of daily
 After 3 days of living (ADL)
nursing  After 3 days of
interevntion the pt nursing
will follow interevntion the pt
pharmacological will be able to
regimen as follow
prescribed. pharmacological
regimen as
prescribed.