ASSESMENT Subjective data: Mahapdi yung balat niys banda sa itaas ng pwetan niya .

Para bang may paso at laging basa. Verbalized by the patients guardian. Objective data: Skin irritation at the upper side of Redness of the skin. Watery appearance of the ulcerated skin.

DIAGNOSIS Impaired skin integrity related to physical immobilizatio n.

RATIONALE Ulcerated skin caused by pressure and lack of movement, and worsened by exposure to urine or other irritating substances on the skin.

PLANNING After a week of nursing interventions, the patient s pressure sore will decrease and will also be prevented.

IMPLEMENTATION Independent: Identify the underlying condition.

RATIONALE Provides information to aid in determining choice of effectiveness of interventions. To determine clients level of understanding and to provide necessary information. Promotes relaxation, and prevention of increase of pressure sores.

EVALUATION After a week of nursing interventions, the patient pressure sore will decrease and will also be prevented as evidence by: Verbalization of decreased pain (scale of 0-10, and duration. Absence or reduce pressure sores.

Encourage to move more frequently or turn from side to side. Identify information that needs to be remembered.

NANDA Provide a schedule for the patients turning movements.

Vital signs taken as follows: T:36.8 P:78 R:21 BP:110/70

Dependent: Administer prescribed medications. Collaborative: Provide for individualized therapy/exercise program that can be continued by the client when discharged. Promotes active not passive role.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Masakit ang tiyan ko. Parang ang bigat bigat ng tiyan ko Objective: Restlessness Irritability Facial grimace

Acute Pain r/t on accumulation of fluid in the abdomen evidenced by verbal reports of pain in the abdomen

GOAL: After 5 hours of nursing interventions, the client will be able to control her pain. 1. Nurse will provide The client needs to understand the health teaching on the importance of pain relief to get importance of pain relief. his cooperation.

After 5 hours of nursing interventions, the client was able to control her pain.

Vital signs: B.P. 110/70 P.R. 103 R.R. 19 TEMP. 36.9 2. Perform an assessment of pain including the location, characteristics, onset/duration, quality, and severity (0-10 on pain scale) Note any presence of deviations. Assessing the characteristics of pain will help in planning what type of intervention will be done to reduce the clients pain.

3. Assist client to explore This will guide/help methods for the client in alleviation/control of alleviating/controlling his/her

pain. Encourage verbalization of feelings about the pain.

pain. This is to help the client voice out his/her feelings regarding his/her condition for the healthcare provider to know the current situation of the client. Administering medications such as analgesics will help in pain relief.

Administer medications as ordered.

This is to prevent fatigue. 4. Encourage adequate rest periods. Review ways to lessen pain, including techniques. This is for the client to gain knowledge on how to manage pain when possible reoccurrence of condition occurs.