ASSESSMENT

DIAGNOSIS

INFERENCE

GOALS AND OBJECTIVES GOAL: After 7 days of nursing intervention, the client will be free from injury. OBJECTIVES: After 8 hours of nursing intervention, the client will Understand the risk factors that contribute to possibility of falls. Demonstrate behaviours that reduce risk factors and protection from self injury. Modify environment as indicated to enhance safety.

INTERVENTION

RATIONALE

EVALUATION

*Ambulatory with assistance

Risk for fall related to physical immobility

Increased susceptibility to falling that may cause physical harm due to physical immobility. Pain is a factor that may contribute because there is a presence of acute illness.

Observe individuals general health status. Consider environmental hazards in the care setting.

To evaluate the degree of risk.

To identify deficits that provides opportunities for intervention and interaction. To assist client in reducing individual risk factors.

After 7 days of nursing intervention, the client is now free from injury. After 8 hours of nursing intervention, the client understood the risk factors that contribute to the possibility of falls. The client demonstrated some behaviour that reduced risk factors and protection from self injury. Also, the client modified the environment as indicated to enhance safety.

Discuss consequences of previously determined risk factors.

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DIAGNOSIS

INFERENCE

GOALS AND OBJECTIVES Short Term Goal Within 1 hour of nursing intervention the client fatigue will be lessened by verbalizing that he was be able to sleep and a feeling of being refreshed, increase in concentration Long Term Goal Within 3 weeks of nursing intervention. Clients fatigue will be eliminated as manifested by: Ability to perform activities of daily living. Able to stand and ambulate without

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE Hindi ako makatayo.. as stated. Hindi na ako makatulog kasi kumikirot yung mga kalamanan ko sa binti at sa paa; tinitiis ko na lang as stated OBJECTIVE Difficulty of moving lower extremities Soft voice Speaks slowly Slow reaction Appears exhausted Irritable Inability to

Fatigue related to poor physical condition secondary to sleep deprivation.

Pain felt by the client during the illness period leads to deprivation of rest and sleep. Resulting to exhaustion, irritability, lack of concentration, of which all can be signs of fatigue.

Monitor vital signs. Assist with selfcare needs, as necessary.

To evaluate fluid status and cardiopulmonary response to activity. Generalized weakness may make activities of daily living almost impossible for client to complete. The client needs adequate, properly balanced intake of carbohydrates, fats, protein, vitamins and minerals to provide energy resources. Bright lighting, noise, visitors, frequent distractions and clutter in the patients physical environment can

After 1 hour of nursing intervention lessened fatigue is manifested. Verbalized that he was able to sleep, a feeling of being refreshed. Increase in concentration is also observed. After 3 weeks of nursing intervention. Clients fatigue was eliminated. Manifested: Able to perform activities of daily living such as bathing, standing and walking with ease is possible

Provide recommendations for nutritional intake for adequate energy sources and metabolic requirements.

Minimize environmental stimuli, especially during planned times for rest and sleep.

concentrate Drowsy

any assistance.

inhibit relaxation, interrupt rest and contribute to fatigue. Encourage to drink fluids. It is important to keep up fluid intake as even mild dehydration can cause fatigue. Dehydration can also lead to an increase in blood sugar. Calming herbal teas are more beneficial than caffeine based drinks. Deep breathing exercises can help turn off the bodys stress switch and reduce blood sugar levels. Sedatives ease agitation and permitting sleep. Treatment of disease can provide complete

Instruct to breathe more evenly, deeply and slowly.

Give medications like sedatives as ordered. Treat the underlying cause.

ASSESSMENT

DIAGNOSIS

INFERENCE

GOALS AND OBJECTIVES SHORT TERM: After 30 minutes of nursing interventions, the clients pain will decrease from moderate to mild as evidenced by: Pain scale of 2/10 (classified as mild) Verbalization of decrease of pain and an increase in appetite LONG TERM: After 1 month of nursing intervention, the client will be able to maintain and have a normal body weight as evidenced by: Weight of 62.1 kg

INTERVENTION

RATIONALE

EVALUATION

Subjective: Masakit ang tiyan ko. Hindi na nga ako maysadong nakakakain dahil masakit. As verbalized by the patient. Objective: Epigastric pain; pain upon palpation Pain scale of 5/10 classified as moderate Weight: 52.2kg Height: 169cm BMI: 18.38% Desired body weight (using Tannhausers Method)= 62.1kg 1 Malnutrition

Imbalance Nutrition: Less than body requirements related to inability to ingest food secondary to pain

The bacteria Leptospirosis interrogans that causes leptospirosis enters the body through wounds, eyes, and other membranes. The bacteria multiply inside the body and then cause inflammatory reaction (redness, swelling, heat, pain). Prolonged infection leads to organ invasion and body pain develop. Pain now reduces the appetite of the client.

INDEPENDENT: Observe and record To assess what intake (solid and nutrients patient liquid) consumes and what supplements he needs. Determine food preferences; offer food that appeal to the tactile, visual and olfactory senses. Offer high-protein, high-calorie diet To enhance or increase the patients appetite.

SHORT TERM: After 30 minutes of nursing interventions, the goals are met as evidenced by: Pain scale of 2/10 (classified as mild) Verbalization of decrease of pain and an increase in appetite

Such foods prevents body protein breakdown & provide caloric energy To monitor effectiveness of dietary plan

LONG TERM: After 1 month of nursing intervention, the goals are partially met as evidenced by: Weight of 60 kg

Weigh patient, same time everyday DEPENDENT: Administer analgesics as prescribed by the

To decrease pain so that the client will be encouraged

Brown with gray tinged stool Normal bowel sounds (10/min)

physician COLLABORATIVE: Consult with dietitian/nutritionist

to ingest food

ASSESSMENT

DIAGNOSIS

INFERENCE

GOALS AND OBJECTIVES LONG TERM: After 10 days of nursing care, client will be free of hepatomegaly as evidenced by: Absence of jaundice and graytinged stool Palpating of a normal-sized liver

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Nasusuka ako tapos nagsusuka din ako nung mga unang araw ko dito. As stated. Masakit pag ginalaw ang tyan ko. Verbalized client upon palpation of right upper quadrant

Ineffective tissue perfusion r/t impaired tissue integrity

OBJECTIVE: Normal bowel sounds (10 per minute) but with passage of graytinged stool Pain on right upper quadrant upon light palpation Pain scale of 5/10 Passing of vomitus

Untreated leptospirosis will result in the Leptospira interrogans to invade body organs, in this case, the liver. Invasion to the liver will result in damage to mucosal lining and enlargement of the liver (hepatomegaly) which will lead to two things: 1. Decrease in liver function which will lead to inability to secrete excess bilirubin that will ultimately result in jaundice and gray-tinged stool 2. Compression of nearby organs which will lead to pain and

INDEPENDENT: Note customary baseline data

Provides comparison with current findings To monitor if the condition is getting worse or not

Note reports of N/V, changes in stool frequency/ characteristics, presence of blood Provide small/ easily digested food and fluids when tolerated Demonstrate/ encourage use of relaxation activities, exercises/ techniques DEPENDENT: Administer Benzyl Penicillin 2, 2 units, IV push q6 Administer Paracetamol 300mg/IV q4 for

LONG TERM: Goal partially met. After 10 days of nursing care, client was free of hepatomegaly and gray-tinged stool but still have some traces of jaundice

To prevent indigestion resulting from bulky foods To decrease tension level

SHORT TERM: After 4 hrs of nursing intervention, clients right upper quadrant pain will lessen as evidenced by: Pain scale report of 2-3/10 No report of pain upon palpation of right upper

To treat infection

Acts as an analgesic as well as an antipyretic

SHORT TERM: Goal fully met. After 4 hours of nursing intervention, clients right upper quadrant pain was lessened as evidenced by: Pain scale report of 2/10 No report of pain upon palpation of right upper quadrant

tenderness upon palpation REFERENCE:

quadrant

temp= 38.5

which can minimize mild pain

COLLABORATIVE: Review specific dietary changes/restrictions with client

Patients with compromised liver function will need less protein in their diet

ASSESSMENT

DIAGNOSIS

INFERENCE

GOALS AND OBJECTIVES SHORT TERM: After 5 days of nursing intervention the client will be able to demonstrate relaxation skills and diversional activities to reduce pain as evidenced by:

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Patient was asked Masakit ba yung katawan mo? Patient answered Oo Patient was asked yung binti ninyo po masakit? Patient answered Masakit siya pero mas masakit siya kapag hinahawakan o ginagalaw yung binti ko Pain scale: 9/10 OBJECTIVE: RR: 30 bpm (+) guarding behaviour (+) facial grimace

Acute pain related to impaired tissue integrity

Infection is initiated through indirect contact with urine of infected animal (when walking in flooded area). Leptospira spp. Enters the body (blood vessels) and the bacteria multiplies on the bloodstream and adheres to different organs and tissue in the body during the 2nd phase of the disease that leads to generalized body pain specifically on the muscles.

INDEPENDENT: Obtain clients assessment of pain (location, characteristics, onset and duration, frequency, quality, intensity and precipitating factors)

To rule out worsening of underlying condition or development of complications

Observe nonverbal cues and pain such Observations may not be congruent Pain scale reduces as facial grimace with verbal reports and guarding from 9/10 to 6/10 behavior RR within normal Monitor skin color rate It is usually altered and temperature in acute pain and vital signs Absence of diaphoresis To promote non Provide comfort Reduced facial pharmacological measures like grimace pain management repositioning, touch and use of Decreased hot or cold packs irritability Increased Encourage the use To distract attention of relaxation

SHORT TERM: After 5 days of nursing intervention the goal was fully met the client demonstrated relaxation skills and diversional activities to reduce pain as evidenced by: Pain scale reduces from 9/10 to 6/10 RR within normal rate Absence of diaphoresis Reduced facial grimace Decreased irritability

(+) pain on calf upon palpation Irritable Diaphoresis Reduced interaction with people

interaction with people

techniques such as and reduce tension breathing and imagery Encourage diversional activities such as watching TV, listening to music or radio Encourage adequate rest periods Help patient into a comfortable position

Increased interaction with people LONG TERM: After 2 weeks of nursing intervention the goal was fully met the client was free from pain as evidenced by: (-) pain upon palpation

LONG TERM: After 2 weeks of nursing intervention the client will be free from pain as evidenced by: (-) pain upon palpation Absence of guarding behaviour Absence of facial grimace

To help patient focus on non-pain related matters

To prevent fatigue

To reduce muscle tension

Absence of guarding behavior Absence of facial grimace

ASSESSMENT

DIAGNOSIS

INFERENCE

GOALS AND OBJECTIVES LONG TERM: After 2 weeks of nursing intervention the client will regain and maintain muscle mass and strength as evidence by: Client will maintain maximum ROM on lower extremities Client will perform ADL and desired activities Client will show no more facial grimacing when moving Client will state relief of pain from 9/10 to 0/10 SHORT TERM: After 8 hours of nursing

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Hindi ko magawa yung trabaho ko kasi hindi ako makatayo sa sobrang sakit ng katawan ko lalo na yung binti ko. , as verbalized by the client OBJECTIVE: -Limitd ROM on lower extremities -(+) facial grimace when the leg was asked to raise -difficulty turnng -pain scale 9/10 -patient appears weak

Activity Intolerance r/t Immobility secondary to Pain

Modifiable Risk: Contaminated flood

MOT: lesion/rash on the sole of the foot

Turn and reposition Turning and patient at least repositioning every two hours prevents skin breakdown and atelectasis and improve lung expansion.

Long term goal has met as evidence by: Client is able maintain maximum ROM on lower extremities Client can perform ADL and desired activities Client shows no more facial grimacing when moving Client stated the relief of pain from 9/10 to 0/10 Short term goal has met as evidence by: Client enumerates techniques that enable resumption of activities such

Enter of Leptospira spp in the body

Teach isometric exercise

This will help client to increase muscle tone and prevent contracture This will improve clients selfconcept an motivate to form ADL This will help to assess the location, quality and intensity of pain

Multiplication of bacteria in the bld stream

Provide emotional support and encouragement

Inflammatory reaction of the body

Encourage to verbalize pain and discomfort and observe nonverbal cues for pain

Pain in the calf area

Implement ROM exercise, progress from passive to

This will help client to increase muscle

Adherence of bacteria in different body organs and tissue

Generalized body pain(muscle)

intervention the client will understand the importance of maximum activity level as evidence by: Client will enumerate techniques that enable resumption of activities such as isometric exercise. Client will express willing to participate in care

active ROM

tone and prevent contracture and maintain joint mobility

as isometric exercise. Client expressed willing to participate in care

Reduction of muscle strength

Impaired ability to maintain activity

Inability to perform activity

Activity Intolerance

ASSESSMENT

DIAGNOSIS

INFERENCE

GOALS AND OBJECTIVES SHORT TERM: After 20 minutes of nursing intervention the client will verbalize understanding of individual factors that contributed to contamination and plans for correcting situations where possible as evidence by : Identify hazards that leads to contamination Verbalize necessary actions to promote safety LONG TERM: After 1 month of nursing intervention the client will be able to change his lifestyle as evidence by:

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Pt. verbalized: 1 month ago pumunta ako ng Mindoro para magdeliver ng tinapay. Bumaha doon.Wala akong ginamit na boots. Sumulong ako sa baha nakatsinelas lang . Pt verbalized: hindi ko alam na kpag lumusong ako magkkaganito ako. OBJECTIVE: (+) for Leptospirosis disease

Contamination related to lack of protective clothing

Leptospirosis is a worldwilde disease caused by bacteria called leptospires. Rat is the common main host. Mode of transmission through contact of the skin, especially to open wounds with water like flood, moist soil or vegetation contaminated with urine of the infected host then clinical manifestation will appear.

Independent: Ascertain type of contamination to which client has been exposed.

To identify source and to prevent him from contamination.

Teach client to follow decontamination plan (e.g removal of clothing,clean lower extremities with soap and water .) Ensure availability of personal protective equipment (e.g use of raincoats and boots during rainy season).

To prevent further contamination and for hygienic purposes.

SHORT TERM: After 20 minutes of nursing intervention the client verbalized understanding of individual factors that contributed to contamination and plans for correcting situations where possible as evidenced by : (fully met) Identified hazards that leads to contamination Verbalized necessary actions to promote safety LONG TERM: After 1 month of nursing intervention the client was able to change his lifestyle as evidenced by:

To protect from exposure from possible contaminants.

Review individual nutritional need, appropriate exercise program, and need for rest.

Essential for well being and recovery.

(fully met) Use protective gear during rainy season Eat nutritious food Ate nutritious food. Used protective gear during rainy season.

ASSESSMENT

DIAGNOSIS

INFERENCE

GOALS AND OBJECTIVES LONG TERM: After 2 days of nursing intervention client initiate necessary lifestyle changes as evidenced by: Will ask SO to clean house that the rats may live in. Will state bibili na nga ako ng bota, tagulan, delikado at mahirap na din magkasakit ulit Will state ang leptospirosis pala ay nakukuha sa baha at delikado ang nagkakalagnat pag lumusong sa baha, dapat pala ay nakapagpatingin na ako sa doctor para di na lumala

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Hindi ko kasi alam na leptospirosis na pala to kaya di na muna ako nagpacheck sa doctor

Knowledge Deficit evidenced by statement of misconception and development of preventable disease.

Client was not aware of the disease process thus ignoring it and

INDEPENDENT: Review disease process and future expectations.

Provides knowledge base from which patient can make informed choices. -Job that may include animals -Skin Breakage -Waterlogged skin -Exposure to pathogens -Contaminated drinking water -Contaminated flood -Low Immune system -Respiratory (contaminated water must be aerosoled) -Ingestion -Exposure of mucous membranes, conjunctiva. To know what different method can he use to protect his self to the organism thus preventing the disease process.

OBJECTIVE: Development of preventable complication

Review individual risk factors and mode of transmission/portal of entry of infections.

LONG TERM: After 2 days of nursing intervention client initiated necessary lifestyle changes as evidenced by: Client asked SO to clean house that the rats may live in. Stated bibili na nga ako ng bota, tagulan, delikado at mahirap na din magkasakit ulit Stated ang leptospirosis pala ay nakukuha sa baha at delikado ang nagkakalagnat pag lumusong sa baha, dapat pala ay nakapagpatingin na ako sa doctor para di na lumala

Promote health teaching about prevention of transmission

SHORT TERM: After 4 hours of nursing intervention client Verbalize understanding of therapeutic needs evidenced by: -client states kailangan ko pala magpacheck up kung tumagal ang lagnat ko lalo na ngayon tagulan, kailangan din palang palakasin ang katawan kasi uso sakit ngayon sa tubig ano?

Provide information about drug therapy, interactions, side effects, and importance of adherence to regimen. Discuss need for good nutritional intake/balanced diet. Encourage adequate rest periods with scheduled activities. Review necessity of personal hygiene and environmental cleanliness, proper cooking techniques/food storage. DEPENDENT: Discuss it with SO

Promotes understanding of and enhances cooperation in treatment/prophylaxis, and reduces risk of recurrence and complications. Necessary for optimal healing and general well-being.

Thus long term goal is fully met SHORT TERM: After 4 hours of nursing intervention client verbalized understanding of therapeutic needs evidenced by: Client stated kailangan ko pala magpacheck up kung tumagal ang lagnat ko lalo na ngayon tagulan, kailangan din palang palakasin ang katawan kasi uso sakit ngayon sa tubig ano? Thus short term goal is fully met

Prevents fatigue, conserves energy, and promotes healing.

Helps control environmental exposure by diminishing the number of pathogens present.

So if ever the client forgets, SO can easily

remind him, SO may also convince him to participate in the prevention and health promotion regimen

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GOALS AND OBJECTIVES

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GOALS AND OBJECTIVES

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GOALS AND OBJECTIVES

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GOALS AND OBJECTIVES

INTERVENTION

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