ASSESSMENTS NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Acute pain related to STO: Independent:
destruction of
Subjective: After 5-6 hours of 1. Explained/acknowledged reality of Goal met. After a series
peripheral nerves 1. Knowing about these
nursing intervention the phantom-limb sensations, that they sensations allows patient to of nursing interventions,
secondary to
patient will be able to are usually self-limiting, and that understand this is a normal the client verbalized
amputation
“Sakit jud ning akong will verbalize various modalities will be tried for phenomenon that may develop understanding regarding
naputol na tiil ” understanding of pain relief immediately or several weeks phantom pain and
phantom pain and 2. Provided general comfort measures postoperatively. methods to relieve pain
As the patient verbalized. methods to provide (e.g., frequent turning, back rub) 2. Refocuses attention, promotes as evidenced by reduced
Pain scale of 6 out of 10. relief. and diversional activities relaxation reports of pain and
3. Encourage use of stress 3. May enhance coping abilities appear relaxed and able
management techniques (e.g., deep- and may decrease occurrence to rest/sleep
breathing exercises, guided of phantom limb pain appropriately.
imagery) and therapeutic touch. 4. May be used to promote
Objective: LTO: muscle relaxation and
4. Provided warm compress as
enhance circulation
 Guarding behaviour indicated
5. Aids in evaluating need for
 Weakness 5. Reassessed location and intensity of and effectiveness of
After 1 month of nursing
 Right leg amputated interventions, the client
pain (0–10 scale). interventions. changes may
will be free from investigate changes in pain indicate developing
o HGT: 250(70- experiencing pain in the characteristics e.g.,numbness, complications, e.g.,
110mg/dL) genital area tingling necrosis/infection
o FBS:8.81 (3.3-5mmol/L 6. Encourage patient to report of 6. May indicate developing
o Glycosylated progressive/ poorly localized pain compartment syndrome.
hemoglobin: 7 (<7%) unrelieved by analgesics.

Dependent:
1. Administer prescribed
 medication Reduces and relieve pain
 Enoxaparin 40 mg SQ q 24hr
 Pregabalin 50mg 1 cap BID
 Dolcet 1 tab BID
 Tramadol 500 Q 6h

Collaborative:
Nutrition diet ( DM diet )
 ASSESSMENTS NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Impaired Physical m STO: Independent:
obility related to loss
Subjective: After 5-6 hours of 1. Provided stump care on a routine Goal met. After a series
of limb secondary to 1. Provides opportunity to
nursing intervention the basis, e.g., inspect area, cleanse and of nursing interventions,
“Dili na bah okay wala amputation. evaluate healing and note
patient will be able to dry thoroughly, and rewrap stump the client verbalized
naman akong tiil ” complications. Wrapping
maintain position of with elastic bandage understanding regarding
function and demonstrate
helps form stump into conical
As the patient verbalized. phantom pain and
techniques or behaviours shape to facilitate fitting of
methods to relieve pain
that enable resumption of prosthesis.
2. Measured circumference of the as evidenced by reduced
activities. 2. Measurement is done to
stump periodically reports of pain and
evaluate if the edema has
appear relaxed and able
Objective: reduced thereby helping to
to rest/sleep
lessen burden in movingECG: the NSTE-ACS
 Reluctance to attempt appropriately.
affected limb.
movement 3. Instructed and assisted with
3. Prevents contracture and
 Impaired coordination specified ROM exercises for both
LTO: deformities. The presence of
 Amputated left lower the affected and unaffected limbs.
this condition may restrict the
extremity (AKA) movement of the affected
 Vital signs taken as: bone.
 RR=19cpm 4. Encouraged active/isometric 4. Increases muscle strength to
PR=92bpm exercises for upper torso. facilitate transfers /
BP=110/70mmHg and unaffected limbs. ambulation and promote
5. Provided trochanter rolls as mobility and more normal
indicated lifestyle
6. Instructed patient to lie in prone 5. Prevents external rotation of
position as tolerated at least twice a lower-limb stump.
day with pillow under abdomen and 6. Strengthens extensor muscles
lower-extremity stump and prevents flexion
7. contracture of the hip, which
 can begin to develop within
24 hr of sustained
malpositioning.

Dependent:
2. Administer prescribed
medication Reduces and relieve pain
 Enoxaparin 40 mg SQ q 24hr
 Pregabalin 50mg 1 cap BID
 Dolcet 1 tab BID
 Tramadol 500 Q 6h

Collaborative:
Nutrition diet ( DM diet )
 ASSESSMENTS NURSING PLANNING INTVERVENTIONS EVALUATION
DIAGNOSIS
Fatigue related to Short Term: INDEPENDENT Goals are met.
Increased energy After 2-3º of nursing
Subjective: interventions, the
demands: hyper
“Hawaoy kaayo akong lawas ” as metabolic patient will be able to 1. Assess response to activity 1. Response to an The patient shall have been
verbalized by the SO state/infection identify measures to activity can be able to identify measures to
conserve and increase conserve and increase body
evaluated
body energy. 2. Asses muscle strength of energy
2. To determine the
Long Term: patient and functional level of The patient shall have been
Objective: level of activity
activity.Discuss with patient the 3. Education may free from signs of fatigue
After 1-2 days of need for activity provide motivation
nursing interventions, 3. Discuss with patient the need to increase activity
 generalized weakness the patient will be free for activity level even though
 iIncreasedrespiratoryrate of from signs off Fatigue patient may feel too
25cpm weak initially
 presence of non-healing 4. Prevents
wound on right foot with pus 4. Alternate activity with periods excessivefatigue
–filled swelling of rest/ uninterrupted sleep. 5. Indicates
 body weakness 5. Monitor pulse, respiration rate physiological
 Wt. loss and blood pressure before/after levels of tolerance
 Fatigue activity Tolerance develops
 Limited ROM by adjusting
 Inability to perform ADL frequency, duration
and intensity until
altered sensorium desired activity level
is achieved.
Labs: 6. Perform activity slowly with 6. Interventions should
frequent rest periods
o HGT: 250(70-110mg/dL) be directed at
o FBS:8.81 (3.3-5mmol/L delaying the onset
o Glycosylated hemoglobin: 7 of fatigueand
(<7%) optimizing muscle
efficiency.
Dependent:
Administer medication as
prescribed
 Insulin glargine 10units sc pc
 Insulin glulisine 4 units

 Mosegor vita 1 tab OD

 Aminobrain 1 tab OD

Collaborative:
Nutrition diet ( DM diet )
 ASSESSMENTS NURSING PLANNING INTVERVENTIONS EVALUATION
DIAGNOSIS
Altered Fluid Volume Short Term: INDEPENDENT Goals are met.
r/t intracellular DHN 2°
Subjective: After 3° of NI, patient
the DM II
“Hawaoy kaayo akong lawas ” as shall have verbalized 1. Establish rapport 1. Friendly relationship The patient was able to
verbalized by the SO understanding of with patient and to maintained fluid volume at a
causative factors and be able to each functional level as evidenced
purpose of individual other’s concern by individual good skin
therapeutic 2. Take and record vital signs 2. To have baseline
Objective: interventions turgor, moist mucous
data membrane and stable vital
andmedications. 3. Assess skin turgor and mucous 3. Dry skin and mucous
signs
membranes for signs of membranes are signs
Long Term: dehydration of dehydration
 Increased urine output
 Thirst 4. Encourage the patient to 4. Dry skin and mucous
 Exhaustion After 2 days of NI, the increase fluid intake membranes are signs
 Weight loss\ patient shall have of dehydration
 Dry skin or mucous maintained fluid volume
membranealtered sensorium at a functional level as Dependent:
 Edema on Right leg evidenced by individual Administer prescribed medication
good skin turgor, moist  Furosemide 40 mg 1 trab
mucous membrane  Calcium carbonate 1 tab BID
 Human albumin 20% 50 ml
IV drops for 2 hours

Creatinine: 126.51(71-115umol/L

Albumin: 21.1(35-54g/L Collaborative:

Calcium: 1.00(2.2-2.7mmol/L) Nutrition diet ( DM diet )
 ASSESSMENTS
Subjective:
“Naniwang nakog samot ” as
verbalized by the SO
Objective:
 Poor muscle tone
 Generalized weakness
 Increased thirst
 Increased urination
 Ppolyphagia
 Loss of weigh\
o HGT: 250(70-110mg/dL)
o FBS:8.81 (3.3-5mmol/L
o Glycosylated hemoglobin: 7
(<7%)
NURSING PLANNING INTVERVENTIONS EVALUATION
DIAGNOSIS
Imbalanced Nutrition: Short Term: INDEPENDENT Goals are met.
less than body After 3° of NI, patient
shall have verbalized 1. Establish rapport 1. Friendly relationship
requirement
r/t insulindeficiency understanding of with patient and to The patient was able to
causative factors when be able to each maintained fluid volume at a
known and necessary other’s concern functional level as evidenced
interventions and
by individual good skin
identified diabetic
client. turgor, moist mucous
2. To determine what
2. Ascertain understanding of membrane and stable vital
information to be
Long Term: individual nutritional needs signs
provided to
3. Discuss eating habits and
client/SO
encourage diabetic diet as
After 1-4 months of NI, 3. To achieve health
prescribed by the Doctor
the patient shall have needs of the patient
demonstrated weight with the proper food
4. Document actual weight, do
gain toward goal. diet for is/her disease
not estimate.
4. Patient may be un
aware of their actual
weight or weight
loss due to
5. Note total daily intake estimating weight.
including patterns and time of 5. To reveal changes
eating. that should be made
in client’s dietary
intake
6. For greater
6. Consult dietician/physician understanding and
for furtherassessment and furtherassessment of
recommend-dation regarding specific foods.
food preferences and nutri-
 tional support

Dependent:
Administer prescribed medication
 Mosegor vita 1 tab OD Food supplement and
 Aminobrain 1 tab OD vitamins

Collaborative:
Nutrition diet ( DM diet )
 ASSESSMENTS NURSING PLANNING INTVERVENTIONS EVALUATION
DIAGNOSIS
Altered Fluid Volume Short Term: INDEPENDENT Goals are met.
r/t intracellular DHN 2°
Subjective: After 3° of NI, patient
the DM II
“Hawaoy kaayo akong lawas ” as shall have verbalized 5. Establish rapport 5. Friendly relationship The patient was able to
verbalized by the SO understanding of with patient and to maintained fluid volume at a
causative factors and be able to each functional level as evidenced
purpose of individual other’s concern by individual good skin
therapeutic 6. Take and record vital signs 6. To have baseline
Objective: interventions turgor, moist mucous
data membrane and stable vital
andmedications. 7. Assess skin turgor and mucous 7. Dry skin and mucous
signs
membranes for signs of membranes are signs
Long Term: dehydration of dehydration
 Increased urine output
 Thirst 8. Encourage the patient to 8. Dry skin and mucous
 Exhaustion After 2 days of NI, the increase fluid intake membranes are signs
 Weight loss\ patient shall have of dehydration
 Dry skin or mucous maintained fluid volume
membranealtered sensorium at a functional level as Dependent:
 Edema on Right leg evidenced by individual Administer prescribed medication
good skin turgor, moist  Furosemide 40 mg 1 trab
mucous membrane  Calcium carbonate 1 tab BID
 Human albumin 20% 50 ml
IV drops for 2 hours
Urinalysis

+ 3 Bacteria Collaborative:
+3 sugar Nutrition diet ( DM diet )
+ Protein

+Acetone
 ASSESSMENTS NURSING PLANNING INTVERVENTIONS EVALUATION
DIAGNOSIS
Infectionrelated to Short Term: INDEPENDENT Goals are met.
disease condition. After 4 hours of NPI the
Subjective: risks factors of
1. Encourage client to look
“Naniwang nakog samot ” as occurrence of infection The patient was able to
will be reduce or control at/touch affected body part
verbalized by the SO 1. To begin to identify factors of
to a manageable level incorporate changes occurrence of infection shall
by a clean bed and 2. Encourage verbalization of into body image have reduced or controlled to
maintain skin intact. and role play anticipated 2. to enhance handling a manageable level by a
Objective:
conflicts of potential problems clean bed and skin intact.
Long Term: 3. to prevent
3. Encourage to increase fluid dehydration
 Wound @ Right foot with After 1-2 weeks of NPI, intake 4. to boost immune
purulent-swelling pt will be free of system and promote
 Altered circulation purulent drainage or 4. Increase Vit. C in the diet collagen formation
 Immunological deficit erythema and be 5. for tissue repair
 Weakness afebrile 5. Increase CHON intake 6. to promote healing
 Pale Apperance and prevent
6. Change dressing contamination of the
Lab result: wound
CBC:
WBC: 25.16(5-10 x10 9/L Dependent:
RBC:2.56 (4-6 x 12/L) Administer prescribed medication
Hematocrit: 0.20(0.40-0.54)  Ceftriaxone 1 gm IVTT q8hr Anti bacterial
Hemoglobin::67(130-160 g/L  Co-amoxiclav 625 mg TID
Segmenters: 0.87(0.50-0.65
Collaborative:
Lymphocytes: 0.11(0.25-0.35
Platelet ccount: 690 (140-450 x 10 0/L) Nutrition diet ( DM diet )