ASSESSMENT

Subjective:
Medyo mainit
pakiramdam ko.

DIAGNOSIS
Elevated body
ang temperature related
to direct effect of
circulating endotoxins
on the hypothalamus.

Objective:
Warm to touch on
upper extremities
Flushing of face
Diaphoretic
signs
as
Vital
follows:
T: 37.9 C
PR: 92 bpm
RR: 19 cpm
BP: 100/70 mmHg

SCIENTIFIC
EXPLANATION
The hypothalamus in
the brain, which is the
body's heat regulating
mechanism is affected
by the pyrogens, or
the white blood cells
that are produced to
fight the infection. As
the white blood cells
increase in number,
like an army to fight
the germs, they go
faster
and
faster
attacking the germs,
this
causes
our
bodies to heat up,
thus causing the fever
or
rise
in
body
temperature.

PLANNING
After of 30 minutes
of
nursing
intervention
the
client temperature
will
be
within
normal range.

INTERVENTION

RATIONALE

Independent
Function:
tepid Help
Provided
reduce
sponge bath. Avoid
fever. Note: Use
use of alcohol
of
ice
water
/alcohol
may
cause
chills,
actually elevating
temperature.
.

PLANNING

INTERVENTION

RATIONALE

.
Advised to remove Heat
loss
by
excess clothing or
radiation
and
blankets to promote
conduction.
heat loss. Encourage
Adding clothes or
wearing loose cotton
blanket inhibits the
clothing.
bodys
natural
ability to reduce
body temperature;
where
cold
is
conducted
from
the air to the skin
and from the skin
to
the
blood
vessel.

PLANNING

INTERVENTION

RATIONALE

to Decreases
Instructed
maintain bed rest
stress
and
promotes earlier
recovery.
Promoted a well
ventilated
room A well ventilated
temperature.
room promotes
.
thermoregulatio
n
.

PLANNING

INTERVENTION

RATIONALE

vital To evaluate the

Monitored
signs
closely,
effectiveness
of
especially
the
intervention
temperature(degree
and therapy.
and pattern); note
shaking
chills/profuse
diaphoresis.
Dependent function:
To
support
Administered
replacement fluids
circulating volume
and
electrolytes
and
tissue
such as water
perfusion.

PLANNING

INTERVENTION
RATIONALE
To
Administered
further
antimicrobials and
manage
the
antipyretic
as
client
by
indicated
by
symptomatic
results
of
pharmacological
sputum/blood
treatment.
cultures:
e.g.,Paracetamol
500mg/tab q4 for
>37.8C
Ceftriaxone 2g IV OD
Cefazolin 500mg IV
q8
Clindamycin
300mg/cap q6
Amikacin 500mg IV
q12

INTERVENTION

RATIONALE

Collaborative
Function:
Monitored white Follows progress
blood
cells
and
effects
of
including
disease process/
neutrophils,
therapeutic
lymphocytes,
regimen,
and
monocytes,
facilitates
eosinophils
necessary
and basophils)
alterations
in therapy.

EVALUATION
After a series of
nursing
intervention,
the
goal was met as
evidenced
by
temperature of 37.3
which is within the
normal range.

ASSESSMENT

DIAGNOSIS

SCIENTIFIC
EXPLANATION

Subjective:
Parang may kumikirot
dito , itong pinutol
kong binti.

Acute pain related to

destruction of
peripheral nerves
secondary to
amputation.

When a limb is
amputated,
many
severed
nerve
endings
are
terminated
at
the
residual limb. These
nerve endings can
become inflamed, and
were thought to send
anomalous signals to
the
brain.
These
signals,
being
functionally
nonsense,
were
thought
to
be
interpreted by the

P- Pain even at rest

Q- pricking
R-left leg
S-7/10
T- continuous
Objective:
Guarding behavior
facial grimace
Diaphoretic
Vital signs taken as:
RR=19cpm
PR=92bpm
BP=110/70mmHg

PLANNING
After 1 hour of
nursing intervention,
the
client
will
verbalize
understanding
of
phantom pain and
methods to provide
relief.

INTERVENTION
Independent
function:
Explained/acknowled
ged reality of phantomlimb sensations, that
they are usually selflimiting,
and
that
various modalities will
be tried for pain relief.

RATIONALE

Knowing
about
these
sensations
allows patient to
understand this is a
normal phenomenon
that may develop
immediately
or
several
weeks
postoperatively.
Although
the
sensations
usually
resolve on their own,
some
individuals
continue
to
experience
the
discomfort
for

PLANNING

INTERVENTION

RATIONALE

Provided
general
comfort
measures
(e.g.,
frequent
turning, back rub) and
diversional activities.
Encourage use of
stress management
techniques
(e.g.,
deep-breathing
exercises,
guided
imagery)
and
therapeutic touch.

Refocuses
attention, promotes
relaxation,
may
enhance
coping
abilities and may
decrease
occurrence
of
phantom limb pain.

PLANNING

INTERVENTION

RATIONALE

Provided
warm May be used to
muscle
compress as indicated. promote
relaxation
and
enhance circulation.
Reassessed location
and intensity of pain
(010
scale).
investigate changes in
pain
characteristics
e.g.,numbness,
tingling

Aids in evaluating
need
for
and
effectiveness
of
interventions.
changes
may
indicate developing
complications, e.g.,
necrosis/infection

INTERVENTION

RATIONALE

EVALUATION

.
Encourage patient
May
indicate Goal met. After a
to report of
developing
series of nursing
progressive/ poorly
compartment
interventions,
the
localized pain
syndrome.
client
verbalized
unrelieved by
understanding
analgesics.
regarding phantom
pain and methods to
Dependent:
relieve
pain
as
Reduces
evidenced
by
Administered pain pain/muscle spasms.
reduced reports of
medications
as
pain and appear
ordered
by
the
relaxed and able to
physician
rest/sleep
appropriately.

ASSESSMENT
Subjective:
Wala na ang isa
kong binti, hirap na
akong gumalaw
ngayon.
Objective:
Reluctance to
attempt movement
Impaired
coordination
Amputated left
lower extremity
(AKA)
Vital signs taken as:
RR=19cpm
PR=92bpm
BP=110/70mmHg

DIAGNOSIS

SCIENTIFIC
EXPLANATION

Impaired Physical
Mobility related to loss
of limb secondary to
amputation.

Limb amputation results

in significant changes in
body structures and
functions. Loss of a
limb
produces
a
permanent
disability
that can impact a
patient's
mobility
(movement).
Persons
with amputations may
also experience a wide
range
of
activity
limitations
and
participation
restrictions.
The
physical
capabilities
of
the
individual
and
their
residual
limb
may
change over time. Most
of this change will
happen in the first
weeks
and
months

PLANNING

INTERVENTION

RATIONALE

After 2 hours of
nursing intervention,
the client will be able
to maintain position of
function
and
demonstrate
techniques
or
behaviours
that
enable resumption of
activities.

Provided stump care

on a routine basis,
e.g., inspect
area, cleanse and dry
thoroughly, and rewrap
stump with elastic
bandage

Provides opportunity
to evaluate healing
and note
complications. Wrappi
ng helps form
stump into conical
shape to facilitate
fitting of prosthesis.

Measured
circumference of the
stump periodically

Measurement is
done to evaluate if the
edema has reduced
thereby helping to
lessen burden in
moving the affected
limb.

PLANNING

INTERVENTION
Instructed and
assisted with
specified ROM
exercises for both the
affected and
unaffected limbs.
Encouraged
active/isometric
exercises for upper
torso. and unaffected
limbs.

RATIONALE
Prevents
contracture and
deformities. The
presence of this
condition may
restrict the
movement of the
affected bone.
Increases muscle
strength to
facilitate transfers /
ambulation and
promote mobility
and more normal
lifestyle.
.

PLANNING

INTERVENTION

RATIONALE

Provided trochanter
rolls as indicated.

Prevents external
rotation of lower-limb
stump.

Instructed patient to
lie in prone position
as tolerated at
least twice a day with
pillow under
abdomen and lowerextremity stump

Strengthens
extensor muscles
and prevents flexion
contracture of the
hip, which can begin
to develop within 24
hr of sustained
malpositioning.

INTERVENTION

RATIONALE

EVALUATION

Demonstrated/
assisted with
transfer techniques
and use of mobility
aids, e.g., trapeze,
crutches, or walker.

Facilitates self-care
and patients
independence.
Proper transfer
techniques prevent
shearing
abrasions/dermal
injury related to
scooting.

Goal is met. Client

was
able
to
maintain position of
function
and
improve mobility as
evidenced
by
willingness
to
participate
in
Activities of Daily
Living and desired
activities.