Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective:
Masakit yung
sugat ko, as
verbalized by
the patient.
Objective:
Facial
grimace
Patient with
surgical
incision
noted
Patient at
bed rest
most of the
time.
Pain scale:
!"#
Acute pain r!t tissue
trauma secondary to
Fasciotomy s!c $%&
Inference
tissue trauma from
surgical incision.
%timulates sensory
receptors
'nociceptors( that
responds to
damaging stimuli.
%ends nerve signals
to the spinal cord and
brain
)rain interpretes the
stimuli as pain.
Short erm:
&ithin *+,
hours of nursing
interventions,
the client will
report decrease
pain.
In!epen!ent:
-ssess pain noting
location, pain
scale, duration,
fre.uency, .uality,
intensity or
severity, and
precipitating
factors of pain.
/ncouraged patient
to verbalize about
pain.
Provided comfort
measures such as
deep breathing
e0ercises.
/ncouraged
divisional
activities'12!radio
, socialization with
others, imagery(.
/ncouraged ade.uate
rest 3 sleep.
Depen!ent:
". -dminister
analgesics as ordered
by the physician.
Pain is a
sub4ective
e0perience and
must be described
by the client in
order to plan
effective
treatment.
Promotes
cooperation from
the client.
5eep breathing
calms and soothes
the patient.
5ivert attention
from pain
1o prevent fatigue
3 decrease pain.
/ach client has a
right to e0pect
ma0imum
pain relief.
Short erm: "#oal
met$
-fter * hours of
nursing interventions,
the patient reported
decreased pain as
manifested by:
a. pain scale *!"#
b. resting comfortably
in bed
ASSESS%EN DIA#NOSIS P&ANNIN# INER'ENION RAIONA&E E'A&(AION
Subjective:
Objective:
1emp: 67.8 9
::: ;; bpm
P:: <8 bpm
warm to
touch
hot, flushed
skin
pale 3 weak
in
appearance
Increase! bo!)
temperature r/t
bacterial infection*
OR
+)perthermia r/t to
inflammator)
response as
evidenced by
increase! in bo!)
temperature
greater than
normal range,
flushe! s-in, .arm
to touch*
&ithin ;+*
hours of
effective
nursing
interventions,
the patient=s
temperature will
decrease as
evidenced by:
a. temperature
within normal
range
'6,.8+6.8 9(
b. skin is cool to
touch
c. verbalized
understanding
on interventions
to prevent
hyperthermia.
In!epen!ent:
". Monitored 3
recorded vital signs.
;. Provided tepid
sponge bath '1%)(.
5o not use alcohol.
6. :emoved e0cess
clothing 3 covers.
*. Promoted a well+
ventilated area to
client.
8. /ncouraged to
increase fluid intake.
,. Promoted bed rest.
. /ducated significant
others to do 1%) when
client feels hot.
-dvised to use luke+
warm water only 3
+2ital signs provide
more accurate
indication of core
temperature 3 to
provide baseline data.
+1%) helps in
lowering body
temperature, 3
alcohol cools the
body too rapidly
causing shivering.
+1hese decrease
warmth 3 increase
evaporative cooling.
+>ne way of
promoting heat loss is
to have a clear flow
of air in client=s
room.
+?ncrease fluids help
prevent elevated
temperature
associated with
dehydration.
+1o reduce metabolic
demands of o0ygen
consumption.
+1eaching significant
others to do 1%) will
help in knowing what
to do in case of
-fter ; hours of
nursing intervention,
the goal was met as
evidenced by:
a. temp: 6."9
b. skin is cool, absence
of flushing
c. 1he patient 3
significant others
verbalized
understanding on
interventions to
prevent hyperthermia.
include groin 3
armpit.
7. Monitored 2% 3
recheck.
Depen!ent:
". Provided antipyretic
medications as
indicated.
temperature
elevation.
+1o know the
effectiveness of
nursing interventions
done.
+-ntipyretic drugs
inhibit the
prostaglandin that
serves as mediators
of pain 3 fever.
ASSESS%EN DIA#NOSIS P&ANNIN# INER'ENION RAIONA&E E'A&(AION
Subjective:
Objective:
reluctance to
attempt
movement
inability to
move within
the physical
environment
decreased
muscle
strength
limited :>M
'range of
motion(
impaired
coordination
Impaire! ph)sical
mobilit) r/t
musculos-eletal
impairment
&ithin *+,
hours of nursing
intervention, the
client will be
able to
verbalize
understanding
of situation and
individual
treatment
regimen and
safety measures
independently.
". -ssessed motor
skills, developmental
level, 3 capability of
movement.
;. /valuated
presence of pain or
inflammation.
6. 5etermined degree
of immobility in
relation to #@* scale,
noting muscle strength
and tone, 4oint
mobility, balance 3
endurance.
*. /ncouraged bed rest
3 balance between
activity 3 rest.
8. -ssisted with
passive or active
:>M.
,. /ncouraged client
to maintain upright 3
erect posture when
sitting, standing, 3
walking.
. 5iscussed 3
provided safety needs
such as raised chairs 3
toilet seat, use of
handrails in shower or
toilet, proper use of
A-ssessing
determines client=s
uni.ue impairment 3
guide in choosing
nursing interventions.
ABevel of activity 3
e0ercise depends on
progression 3 level
of pain.
A ?dentifies strengths
and deficits and may
provide information
regarding potential
for recovery
A%ystemic rest id
mandatory to reduce
fatigue 3 improve
strength.
AMaintains 3
improves 4oint
function, muscle
strength, 3 general
stamina.
AMa0imizes 4oint
function 3 maintain
mobility.
ACelps prevent
accident in4uries 3
falls.
$oal met:
-fter * hours of
nursing intervention,
the client verbalized
understanding
of situation and
individual treatment
regimen and safety
measures
independently.
wheelchair.
7. 1urning 3
repositioning of client
every ; hours using
ade.uate personnel if
needed.
<. 5emonstrated use
of assistive devices
such as cane, walker,
or trapeze.
AFre.uent turning 3
repositioning relieves
pressure on tissues 3
promote circulation.
AFacilitates self+care
3 client=s
independence.