Nursing

Cues Nursing Diagnosis Inference Objective Rationale Evaluation

Intervention

Subjective ◊ Acute Pain r/t Short Term Goal Independent ◊ After 30 minutes of
fronto-temporal Embryonal subclass nursing intervention,
◊ “Umiiyak sya palagi mass of ◊ After 30 minutes of ◊ Location, character, ◊ Pain limits chest the goal is met
dahil sa pabalik-balik Rhabdomyosarcoma nursing intervention, quality and severity of excursion and thereby through verbalization
na sakit sa ulo nya pain intensity will be pain were evaluated. decreases ventilation. of being free from
gawa nung bukol sa minimized & comfort acute distress and
likod ng kaliwang will be verbalized. ◊ Maintained care in ◊ The patient who is feels much more
mata nia. ,” as affected positioning the patient comfortable and free comfortable. There is
verbalized by the striated muscle on and turned every 2 of pain will be less also no sign of incision
father. head region hours. likely to splint the infection.
chest while breathing.
Objective
◊ Incision area was ◊ These signs indicate
◊ c eyepatch OS, dry tumor development assessed every 8 hours possible infection.
& intact for redness, heat,
induration, swelling
◊ c mass OS and drainage.
pressure,
◊ c dressing L obstruction, ◊ Encouraged deep ◊ This permits residual
eyebrow, dry & pain breathing exercises. air in the pleural space
intact to rise to upper portion
of pleural space and be
◊ (+) facial grimace removed. This also
provides comfort.
◊ irritable

◊ c pain on L fronto Dependent

temporal
◊ Administered ◊ Analgesics give pain
◊ V/S as follows: analgesics as relief on the part of
T= 36.8 °C prescribed. the patient.
P= 112 bpm
R= 25 cpm
 Nursing
Cues Nursing Diagnosis Inference Objective Rationale Evaluation
Intervention

Objective ◊ Altered tissue Embryonal subclass Short Term Goal Independent ◊ After 8 hours of
perfusion r/t of nursing intervention,
◊ c eyepatch OS, dry decreased Hgb Rhabdomyosarcoma ◊ After 8 hours of ◊ Vital signs monitored ◊ This is for baseline the goal is met
& intact concentration in nursing intervention, and recorded. comparison. through observation of
blood AMB tissue perfusion will pinkish lips & nail
◊ c mass OS Hgb = 94 g/L normalize & beds; and absence of
affected maintained. ◊ Assessed circulation ◊ These characteristics other signs of
◊ c dressing L striated muscle on of the foot or hand. of pulses, skin color, circulatory
eyebrow, dry & head region Checked for the capillary refill time and impairment.
intact peripheral pulses, temperature indicates
color, capillary refill impairment in blood
◊ c pale lips & and temperature of circulation.
nail beds over toes tumor development fingers or toes.
& fingers

◊ Hgb level = 94g/L ◊ Encouraged to ◊ This will promote

pressure, perform active ROM venous return and
obstruction, exercises. better circulation.
pain

◊ Advised to eat foods ◊ Iron is a carrier of

impaired blood rich in iron such as oxygen needed for
circulation organ meats, legumes cellular respiration.
& green leafy
vegetables.