Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain related to After 4 hours of - Assess the level - Knowing the level Goal Met. After 4
“masakittalaga tong disease process as nursing intervention, of pain, location of pain that is felt hours of nursing
nararamdamanko” as evidenced by non- the client will report and scale of pain, so it can help intervention, the
verbalized by the verbal cues such as that pain is relieved perceived client. determine client reports that
patient. (+) guarding and and controlled. appropriate pain is relieved and
facial grimace. interventions. controlled.

- Observation of - Changes in vital

vital signs every 8 signs, especially
Objective: hours. temperature and
- Guarding pulse rate is one
behavior, indication of
protecting body increased pain
part experienced by
- (+) facial grimace the client.
- (+) irritability
Vital Signs taken as - Instruct client to - Relaxation
follows: perform techniques can
BP=130/80 relaxation make the client
T=36.9 techniques feel comfortable
P=88 and a little
R=24 distraction to
divert the
attention of
clients to pain so
that they can
help children
reduce the pain.

- Provide a - a comfortable
comfortable position to avoid
position. an emphasis on
the area of injury
 pain.

- Collaboration of - Analgesic drugs

analgesic block the pain
medication. receptors so that
the pain cannot
be perceived.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Activity After 8 hours of -Monitor - To obtain Goal Partially Met.

“Hindi Intolerance related nursing vital/cognitive signs, baseline After 8 hours of
akomakagalawngmaayos, to general weakness, interventions the watching for changes parameters. nursing
kasimasakitangtyanko” imbalance between client will in blood interventions the
as verbalized by the supply and oxygen demonstrate a pressure, heart and client was able to
patient. demand. decrease in respiratory rate; note demonstrate a
physiological signs of skin pallor and/or decrease in
intolerance cyanosis, and physiological signs of
(e.g., blood pressure presence of intolerance
remain within confusion. (e.g., blood pressure
client’s normal remain within
Objective: range). -Determining the -Determining the client’s normal
- Paleness cause of intolerance cause can help range).
- Warm and dry skin activity and determine
- Generalized determine whether intolerance.
weakness the cause of the
Vital Signs taken as physical,
follows: psychological /
BP=130/90 motivation.
T=37.2
P=83 -Assess the suitability -Prolonged bedrest
R=24 of activity and rest can contribute to
every day. activity intolerance.

- Evaluate current -Provides

limitations/degree of comparative
deficit in light of baseline.
usual
status.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Anxiety related to After 24 - Assess the - Preliminary Goal Partially
“nanghihinaako, Threat to or change in hours of level of data of Met. After
natatakotakosapwedengmangyarisakalagayanko health status nursing anxiety, the anxiety is 24 hours of
” as verbalized by the patient. [progressive/debilitating intervention, factors that necessary nursing
disease, terminal the patient influence to intervention,
illness], interaction will verbalize the onset of determine the patient
patterns, role function/ awareness of anxiety. the client’s was able to
status, environment feelings of verbalize
level of
Objective: [safety], economic anxiety. awareness of
anxiety and
- Pallor status. feelings of
the factors
- Cyanosis anxiety.
affecting it
- Difficulty of breathing
- Generalized weakness can be
Vital Signs taken as follows: seen that
BP=130/90 the nurse
T=37.2 can
- Encourage
P=83 minimize /
clients to
R=24 prevent
express
clients
their
from
feelings,
influential
fears and
factor.
perceptions
- Presence
.
and
readiness
of nurses in
handling /
accompany
client
- Assess the during the
client’s period of
expectation anxiety can
s to help clients
 treatment to fulfil a
and care. sense of
- Understand security so
the client’s as to
perception reduce
of stressful anxiety.
situations. - The
presence of
the family
can provide
mental
support to
clients.
- Relaxation
techniques 
can reduce
stress
arising.