ASSESSMENT NURSING OUTCOME PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS IDENTIFICATION
Subjective data: Acute pain related 1. Client will report Short Term: Independent: 1. Soft and sagging mattress, After short term (4hours)
“Ang sakit ng to inflammatory relieved of pain. 1. Recommend or provide a large pillows prevent and long term (2 days) of
katawan ko, hindi changes in joints  At the end of 4 firm mattress or bed board, maintenance of proper body
2. Client will appear hours of nursing nursing intervention, the
ako makagalaw and biological small pillow. Elevate linens alignment, placing stress on
ng matino.” As injury agent relaxed and able to intervention, the with bed cradle as needed. affected joints. Elevation of following goals were met:
verbalized by the (infection) rest client pain scale of bed linens reduces pressure
client. 7 will reduce to 5 on inflamed or painful 1. Client pain scale is
3. Client verbalize out of 10. joints.
ways to relieved reduced from 7 to 2
Objective data: 2. Suggest client to assume a 2. To limit pain or injury to
pain position of comfort while in joint. out of 10
Long Term:
 Guarding
bed or sitting in a chair. 2. Client able to rest
behavior At the end of 2 days of
 Irritability properly
nursing intervention the 3. Place and monitor use of 3. Rests painful joints and
 Unfocused pillows, sandbags, trochanter maintains a neutral 3. Client enumerate
patients will able to:
 Pain scale of rolls, splints, braces. position. Use of splints can ways to relieve joint
7 out of 10.  Have a pain scale decrease pain and may pain
of 2 out of 10. reduce damage to joint,
 Rest without much prolonged inactivity can
result in loss of joint
pain
mobility and function.
 Explain ways to
relieved joint pain 4. Encourage frequent changes 4. Prevents general fatigue
of position. Assist the patient and joint stiffness.
to move in bed, supporting Stabilizes joint, decreasing
affected joints above and joint movement and
below, avoiding jerky associated pain.
movements.

5. Recommend that client to 5. Heat promotes muscle

take a warm bath or shower. relaxation and mobility,
Apply warm, moist decreases pain, and relieves
compresses to affected joints morning stiffness.
several times a day.

6. Encourage the use of stress

 management techniques such
as progressive relaxation,
biofeedback, visualization, 6. Promotes relaxation,
guided imagery, and provides a sense of control,
controlled breathing. and may enhance coping
abilities.
Dependent
1. Administer analgesic
medications as prescribed by
the physician.
1. These drugs control mild to
Collaborative: moderate pain and
inflammation.
1. Assist with physical therapies
such as paraffin glove,
whirlpool baths.
1. Provides sustained heat to
reduce pain and improve
ROM of affected joints.