Assessment Diagnosis Planning Intervention Rationale Evaluation

Independent:
Subjective: Acute pain After series  Performed a comprehensive  The single most reliable Goal met, After series of
“Medyo masakit related to of nursing assessment of pain. Note the indicator of the nursing intervention patient’s
ang lalamunan ko” throat intervention severity of pain, location, existence and intensity pain lessened to manageable
as verbalized by irritation as patient’s pain quality and associated of pain is the client’s elf state, from 7/10 to 5/10.
the patient evidence by will lessened manifestations of pain, report.
frequent to 5/10 or in aggravation factors that
Objective: coughing a increase pain and factors
-with pain scale of manageable that alleviate pain.
7/10 state.
-with facial  Performed pain assessment  To rule out worsening
grimace each time pain occurs. or underlying condition
-with guarding or development of
behavior complications.
-irritable
 Monitor vital signs  Vital signs is usually
altered in acute pain.

 Provided safe and quiet  To provide comfort and

environment. alleviate pain.

 Asked the client to describe  A pain history aids in

past experiences with pain planning and discussing
and the effectiveness of the pain control with the
methods used to manage client.
pain.

 Determined the client’s  A medication history

current medication used.
Dependent
 Administered ordered pain
medication on a schedule
aids in planning pain
treatment.
 Pain is easier to
manage before it
 that helps prevent onset of
pain.
 Determined timing or
precipitants of
“breakthrough” pain when
using around the clock
agents to administer a short
half-life agents.
Health-Teaching
 Provided diversional
activities such as listening to
music, reading books or
magazines.
 Encouraged patient to
do deep breathing exercises.
 Encouraged adequate
rest periods.
 Reinforced the
importance of taking pain
medications.
increases in intensity.
 Pain may occure near
the end of the dose
interval. Pain may occur
spontaneously
requiring use of short
half life agents for
rescue or supplemental
dose.
 Cognitive and
behavioral strategies
can restore the client’s
sense of self control,
personal efficacy and
active participation in
care.
 To promote relaxation.
 To prevent fatigue.
 To keep the pain under
control.
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Independent:
Subjective: Alteration in After series of After series of nursing
1. Assess degree of To know the extent of the
“Ang sakit sakit purposeful nursing intervention patient’s,
immobility of the patient's condition
ng tiyan ko body intervention patient. showing signs of improvement
kapag movements patient’s on movement and activity.
nabangon at related to pain movements 2. Assess respiratory To know if the patient is
natayo ako” as as evidenced will enhanced. function of the patient. having difficulties in
verbalized by by verbal respiration
3. Inspect for localized
the patient. reports.
tenderness, skin warmth To prevent any
and muscle tension on complications associated
Objective: the affected parts. with wearing of braces
-with pain
scale of 10/10 4. Assist with active ROM
-with facial exercises. To maintain mobility and
grimace function of affected parts
-with body 5. Provide safety measures
malaise by raising side rails, To assure protection of
-with guarding assisting when client from injury and fall
behavior ambulating and
-with limited modifying the
movements environment.
To provide knowledge
6. Teach the patient the about the importance of
importance of body body function maintenance
function maintenance.

For better lung expansion

7. Instruct to do deep
breathing exercises. To obtain baseline data

8. Monitor vital signs.

Dependent:

1. Check doctor’s orders

 for medicines to be given
and laboratory tests to be
done for the patient.

2. Administer prescribed
medications, if any.

Collaborative:

1. Interact with the physical To provide continuous

therapist for the exercise exercise and maintenance of
programs of the patient. function

2. Collaborate with the

physician for any Useful in determining
prescribed orders. individual needs,
therapeutic activities.
3. Collaborate with
patient’s family or
significant others and To provide knowledge on
provide health teaching. how to deal with the
patient's condition

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Disturbed sleeping Goal: Independent: Goal:
pattern related to
“hirap na hirap environmental After 8 hours of Assess sleeping pattern disturbance To identify the After 8 hours of nursing
akong matulog nursing causative/contributing interventions, the patient was able
factors as
ng maayos interventions, the factors. to verbalize ways to have adequate
simula ng evidenced by patient will be sleep-rest periods.
maconfine sleepiness. able to verbalize Observe physical signs of stress or
ako”as ways to have fatigue. Objective:
verbalized by adequate sleep-
the patient. rest periods. After 4 hours of nursing
interventions, the patient was able
Objective: Objective: Elevate head of bed. Change to verbalize feeling of being well-
position frequently. rested.
Patient has dark After 4 hours of Keeping the head elevated
circles around nursing Arrange care to provide lowers diaphragm.
the eyes, interventions, the uninterrupted periods of rest,
patient will be especially allowing longer periods For energy conservation and
frequent
able to verbalize of sleep at night when possible. adequate sleep.
yawning, cannot feeling of being
maintain eye well-rested. Provide quiet environment and
contact, and has comfort measures in preparation
short attention for sleep.
span.

Limit fluid intake before bedtime

To relax the body and induce
to sleep.

Assist client with frequent deep

breathing and coughing exercises.
To prevent waking up at the
middle of the night to urinate

For breathing exercises and

relaxation.