ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data:  Acute Pain Short term goal: Independent: Short term goal
 “Masaniton ya related to  After I hour  Investigate  Helpful in evaluation:
ding likod ko inflammato of nursing report of pain, determining Goals are met.
kading sa ry process interventio noting location, pain  After 1 hour
babang parte” and joint n the duration and management of nursing
as verbalized destruction. client’s intensity. Note need and interventio
by the patient. pain will precipitating effectiveness of n, the
lessen or factors and program client’s pain
Pain Scale: 7/10 relieve nonverbal cues. was
pain. lessened
Objective Data:  Encouraged to  -To help reduce from pain
 -acial grimace  After 2 perform muscle tension scale of
noted hours of diaphragmatic 7/10 to
 (+) guarding nursing breathing and 2/10.
behavior interventio relaxation
 Vital Signs are n, the  After 2
as followed: patient will  Divert the  Diversion hours of
BP- 150/100 mmHg demonstrat attention of the techniques nursing
RR-21 cpm e behavior client such as help the client interventio
PR-90 bpm and encouraged to not to focus on n, the
T-37.4 degree Celsius techniques watch the pain itself. patient
to lessen or television, It will also help demonstrat
relieve pain reading, have reinforce ed behavior
some pharmacologica and
conversation l interventions. techniques
to lessened
or relieved
 Provide cold  Application of pain.
and warm cold compress
compress within 24 hours
helps to control
 inflammation
and pain while
application of
warm compress
after 24 hours
helps to
relieved pain
and muscle
spasm

 Limit the client  To prevent

movement and further
maintain body deformity and
mechanics and lessened the
proper body pain
alignment

 Monitor vital  Vital signs are

signs usually affected
when pain is
present

 Encouraged  To prevent skin

frequent breakdown and
changes of prevent further
position every deformity
two hours.
Assist client to
move in bed,
supporting
affected side of
the body.
  Avoid  Additional
environmental stressors can
stimulants intensify
patient’s
perception and
tolerance of
pain.
Dependent:
 Administer  To relieve pain
analgesic as
ordered

 Administer  To relieved
NSAIDs as inflammation
prescribed

Interdependent:
 Monitor  A high level in
laboratories ESR and WBC
such as indicates
hematology infection.
Hematology
also helps to
prevent other
complication
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data:  Impaired Short term goal: Independent: Short term goal
 “Nahihirapan Physical  After 2  Build rapport  Helpful in evaluation:
akong gumalaw” Mobility hours of with the client building Goals are met.
as verbalized by related to nursing connection  After 2
the client pain. intervention and for the hours of
the client communicati nursing
Objective Data will on and intervention
 Limited Range of verbalize interaction the client
Motion understandi process verbalized
 Inability to ng of health easier. understandi
perform action teaching ng of health
as instructed and will  Monitor Vital  Vital Signs teaching
 Weak physical demonstrat Signs are usually and
mobility e behaviors affected demonstrat
to increase when pain is ed
physical present. behaviors
mobility. which
 Encourage  It assists the increased
Long Term Goal: appropriate patient with physical
 After 3 days assistive mobility (to mobility.
of nursing devices. move) until
intervention activity Long Term Goal
, the client restriction is evaluation:
will no longer  After 2 days
maintain or needed. of nursing
increase intervention
strength  Provide  Positive the client’s
and positive approach of enabled to
function of reinforcement the nurse increased
affected or during activity. will help to strength
compensato gain and
ry body confidence function of
part. of the client the affected
to body part.
accomplish
different
activities
such as
changing
position,
doing ROM
(range of
motion)

 Provide a safe  Help to limit

environment: the
bed rails up, incidence of
bed in down fall of the
position, patient and
necessary to prevent
items. further
injury.

 Perform  It provides
passive or data on to
active assistive what extent
Range of the client
Motion can move
exercises to all and cues for
extremities. any physical
problems
and guides
therapy.
  Assess or  To prevent
check the form any
client’s skin
integument infections.
systems such To reduce
as skin for the any
presence of complication
skin lesions s.
from
prolonged
immobility.

 Change  To prevent
position for skin
every two breakdown
hours (with and prevent
proper body further
alignment deformity. It
such as limbs optimizes
and circulation to
extremities ) all tissues
and relieves
pressure.

Dependent:
 Administer  To relieve
analgesics as pain from
prescribed. any
movements
of the client.
Interdependent:
 Refer the  For
client to a appropriate
physical safety
therapist for measures
proper
mobilization
techniques.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data:  Hypertension Short term goal: Independent: Short term goal
 “ nalula ako, related increased  After I  Establish  Helpful in evaluation:
masanit pa vascular hour of rapport with building Goals are met.
kading bung vasoconstriction nursing the client connection and  After 1
ko” as and elevated interventi for the hour of
verbalized by blood pressure. on the communication Nursing
the client. client ‘s and interaction Interventio
blood process easier. n the
Objective Data: pressure client’s
 Facial will blood
Grimace normalize  Determines if pressure
 Unstable  Monitor there are was
balance client’s vital significant normalized
 Vital Signs signs for every alterations in from 150/
are as 4 hours vital signs that 100 to
followed: specifically are possible 110/ 80
BP- 150/100 mmHg Long Term Goal: blood cues for mmHg.
RR-21 cpm  After 2 pressure. underlying
PR-90 bpm days of complications.
T-37.4 degree Celsius nursing Long Term Goal
interventi evaluation:
on, the  Encourage the  Dietary sodium  After 2
client and client to take contributes to days of
her strategies for fluid retention nursing
significant low- sodium and elevated interventio
others will diet blood pressure. n the client
demonstr and her
ate significant
technique others
s, demonstra
behaviors ted
and techniques
strategies  Encourage the  High risk for , behaviors
which client to elevated blood and
help in reduce weight pressure. strategies;
maintaini and explain maintain
ng normal the relevance normal
range of of strict diet. blood
blood pressure
pressure. attained.

 Avoid  Physiological
environmental response to
stimulants physical and/ or
such as noise emotional
and stress. stressors
increased
sympathetic
nervous system
activity and
increased
cortisol
secretion,
therefore
produces
vasoconstriction
and increased
water retention.

 Encourage the  Smoking

client to increases
establish vasoconstriction
healthy living and increases
(avoid blood pressure.
 smoking and Excessive intake
limit the use of alcoholic
of alcoholic beverages also
beverages. increases BP.

 Involve family  Family members

in teaching play an
about important role
hypertension. in supporting
the client’s
effort to adopt
new health
behaviors for
management of
hypertension.

Dependent:
 Administer  To normalize
common blood pressure.
medications
such as:
thiazide
diuretics,
beta- blockers,
angiotensin II
receptor
blockers
(ARB’s)
calcium
channel
blockers, and
angiotensin-
converting
enzyme (ACE)
inhibitors as
prescribed (
Lozartan and
amlodiphine)