ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

Subjective: Acute pain related to Short term: Monitor vital signs. Short term:
“Masakit yung dibdib ko angina as manifested by
at kasukasuhan” as altered circulation caused After 1 hour of nursing Assess pain location, After 1 hour of nursing
evidenced by the patient. by blood hyper viscosity. intervention, the patient’s characteristics, intensity intervention, the patient’s
perception of pain will be with every report of pain. perception of pain is
Objectives: decreased to 5/ 10. decreased to 6/10.
Rationale: Regular
BP: 150/100 Long term: assessment of client’s PARTIALLY MET
+ Grimace pain is a critical as
Chest pain: 8/10 After 1 week of nursing changes in the underlying Long term:
Headache: 8/10 intervention, the patient pain condition.
Joint pain: 7/10 will be able to perform After 1 week of nursing
Paresthesia necessary or desired Assess for patient intervention the patient
Feeling of fullness activities at a pain level complaints of pain and was able to perform
Fatigue less than or equal to the tenderness. necessary or desired
comfort- function goal. activities at a pain level
Rationale: These are less than or equal to the
↑ RBC mass: 7 million/ indicators of peripheral comfort- function goal.
thrombosis, which should
mm3
be reported promptly. GOAL MET
↑ Hemoglobin: 18 g/Dl
↑ Hematocrit: 50%
Use gentle range of
↑ WBC
motion exercises as
(+) Phlebotomy
tolerated. Caution patient
to avoid crossing legs and
wearing restrictive
clothing. Apply cool
compresses or ice.

Rationale:
Elevation may help
increase circulation and
prevent pooling of
hyperviscous blood in the
joints. ROM helps improve
circulation. Ice is used
(short term) to decrease
severe joint pain. 

Administer analgesics as
prescribed. Avoid
analgesics containing
aspirin or nonsteroidal
anti- inflammatory drugs
unless prescribed by the
healthcare provider.

Rationale: To reduce pain.

Analgesics containing
aspirin may exacerbate
bleeding associated with
thrombocytosis (high
number of ineffective
platelets) but may be
helpful in alleviating
microvascular symptoms.

Administer hydroxyurea
as prescribed by the
doctor.

Rationale: It has been

reported to reduce
thrombotic complications
and helps slow the
production of red blood
cells and blood counts.
Encourage use of
nonpharmacologic pain
control such as relaxation
and distraction.

Rationale: These are pain

measures that potentiate
analgesics and do not
have side effect.

Emphasis to the client the

importance of pacing
activity and taking rest
before they are needed.

Rationale: Client will find

that they are able to
perform their ADLs and
achieve goals better when
they are rested.