Name: Rayta, Quenne Kathyrine F.

ASSESSMENT
SUBJECTIVE: Masakit ang katawan ko at nahihirapan akong tumayo As verbalized. (pain scale of 9/10)

DIAGNOSIS
Acute pain r/t after effects of procedure as evidenced by pain scale of 9/10, guarding

PLANNING
STG: After 1 hour of nursing intervention clients report of pain will be able to reduce from 9 to 7.

INTERVENTION
DEPENDENT: Perform pain assessment each time pain occurs. Note and investigate previous reports. -to rule out worsening of underlying condition. Observe non-verbal, especially in patients who cannot communicate verbally. -observation may/may not be congruent w/ verbal reports indicating need for further education. Note cultural and developmental influences affecting pain response. -verbal/behavioural cues may have no direct relationship to the degree of pain perceived. Note when pain occurs. -to medicate prophylactically appropriate.

EVALUATION
STG: Goal met, after 1 hour of nursing intervention clients report of pain reduced from 9 to 7.

behaviour ,sleep disturbance, facial grimace, irritability restlessness, difficulty in communicating. INFERENCE: Activation of peripheral nervous system | Activation of CNS | Transmission of the pain signal to the brain at the spinal cord level. | Transmission of the pain signal to the brain | PAIN

OBJECTIVE: -guarding behaviour -sleep disturbance -facial grimace -irritability -restlessness -difficulty in communicating.

LTG: After 6 hours of nursing intervention, client will be able to report relieved from pain.

LTG: Goal met, after 6 hours of nursing intervention, client report relieved from pain.

as

INDEPENDENT:Administer analgesic as prescribed.

Pata, Rojana

ASSESSMENT
SUBJECTIVE: Sana nung una palang nagpunta na ko sa hospital para hindi na umabot sa ganito, nalulungkot ako sa pagkawala ng baby ko As verbalized.

DIAGNOSIS
Anxiety r/t termination of pregnancy, as evidenced by poor eye contact, facial tension, impaired attention

PLANNING
STG: After 1 hour of nursing intervention client will be able to verbalize healthy ways to deal with and express anxiety.

INTERVENTION
DEPENDENT: Observe behaviour indicative to level of anxiety. -can be a clue to clients level of anxiety.

EVALUATION
STG: Goal met, after 1 hour of nursing intervention clients report verbalized healthy ways to deal with and expressed anxiety.

restlessness, and difficulty in communicating. INFERENCE: Anxiety is a state of fear or a subjective feeling of apprehension, dread, or fore bonding. This psychological state is often accompanied by signs of autonomic activation or other physical symptoms. Anxiety is a universal human emotion that may serve adaptive purposes, but may also be a symptom or syndrome causing suffering and disability.

OBJECTIVE: -poor eye contact -irritability -facial tension -impaired attention -difficulty in communicating.

LTG: After 7 hours of nursing intervention, client will be able to report anxiety is reduced to manageable level.

Be aware of defence mechanism being used. -can interfere with ability to deal with problem. LTG: Goal met, after 7 hours of Review coping skills used in the past. nursing intervention, client -to determine those that might be report anxiety is reduced to helpful in current circumstances. manageable level. Provide accurate information about situation. -helps client to identify what is reality based. Allow the behaviour to belong to the client; do not respond personally. -because this may escalate the situation.