ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Data: Acute Pain There is both a Independent: GOAL MET

related to tissue nociceptive and  Measuring pain enables
“Masakit po yung trauma and neuropathic Short term: 1. Assess pain score of the the nurse to assess the Short term:
tuhod ko hanggang effects of cancer component of patient every two hourly amount of pain the patient
sa may bukung- secondary to bone cancer pain. After 3 hours of and on need basis is experiencing. After 3 hours of
bukong. Sobrang disease process nursing interventions, nursing interventio
sakit po para akong as evidenced by The nociceptive the patient will to: 2. Assess muscle strength,  Changes or limitation in the patient was ab
kinu-kuryente.” As patient’s pain component is gross and fine motor strength and coordination to:
verbalized by the score 8/10 and caused by bone-  Verbalize coordination. serve as an identifier for
patient altered vital destroying decrease of pain and metastasis  Verbalize
signs. osteoclasts, and pain from 8/10 decrease of
Objective Data: mechanical to 6/10. Using 3. Provide preventive pain from 8
destabilization the pain scale measures such as  Primary function is to to 6/10. Usi
 Presented to and fracture of of 0-3 as mild, pillows for cushion and provide direct support for the pain sca
the hospital the bone. 4-6 as support. the affected area and to of 0-3 as m
with right moderate, and minimize pressure. 4-6 as
knee pain The neuropathic 7-10 as severe moderate, a
 Patient’s pain component is pain. 7-10 as sev
score 8/10 (10 induced by tumor 4. Provide comfort  Pressure, warmth, or cold pain.
being the cell growth which measure such as back is used on the skin, while
highest, 1 injures and Long term: rub or hot or cold the feeling of pain is Long term:
being the destroys the application lessened or blocked.
lowest) distal ends of After 3 days of These can also be used to After 3 days of
 Pain on nerve fibers that nursing interventions, stimulate the skin. These nursing interventio
resisted normally the patient will report: techniques also change the patient will rep
flexion and innervate the the flow of blood to the
extension bone.  Progressive area that’s stimulated that Progressive decrea
 Pain on active decrease may lessen pain during in pain score with
or passive In bone cancer in pain score the stimulation and for increase in activitie
range of pain there is with an hours after it’s finished. of daily living
 motion of the frequently a increase in After 3 days of
right ankle peripheral and activities of nursing interventio
 Light palpation central daily living. the patient was ab
to the sensitization to report:
proximal fibula resulting in
and tibia primary  Progressive
resulted in hyperalgesia 5. Provide quiet  To prevent or lessen pain. decrease
severe pain environment and calm in pain scor
 VS as follows: activities. with an
increase in
T= 36.9 6. Encourage the patient to  Proper hydration can help activities of
PR= 100 increase fluid intake. reduce pain and protect daily living
RR= 24 your joints and muscles by
BP=100/70 keeping the cartilage soft
and pliable. Dehydration
pulls fluid out of your
tissues, which causes
overall body aches and
pain.

7. Teach deep breathing  to lessen tension, reduce

exercise and relaxation anxiety, and manage pain
techniques.

 Distraction may be used

8. Encourage mind
diversion therapies
alone to manage mild pain
or used with medicine to
manage brief bouts of
severe pain, such as pain
related to procedures
 9. Encourage rest periods
to prevent fatigue.
  Sleep or rest periods, give
more energy, make pt.
less tired, reduce anxiety,
and help other pain-relief
methods work better

Dependent:

1. Administer analgesics as  Pain management using

indicated to maximal pharmacologic methods is
dose as ordered. vital in cancer therapy

2. Administer antiemetic to  Pain management using

prevent from the pharmacologic methods is
adverse effects of pain vital in cancer therapy
killers as ordered.
 ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATION RATIONALE EVALUATIO
   
Subjective: Ineffective Chemotherapy
protection related medications work Short term: Independent Short term:
The client stated, to Impairment of by attacking cells,
primary defense or by preventing After 24 hours of 1. Monitor vital signs  Provides knowledge on After 24 hours o
“Minsan po parang secondary to cells from growing nursing every 4 hours or a any sign or symptoms nursing
ang bilis ko manghina Antineoplastic drug and dividing. intervention, the ordered. due to bone marrow intervention, the
at mahingal.” therapy as patient will be able suppression and patient will be a
  manifested by Cancer cells tend to to  Maintain or immunosuppression to  Maintain or
Objective: deficient immunity grow and divide improve resulting from improve
and infections rapidly and body’s defences by: chemotherapy. body’s defences
 Previous uncontrollably.
episodes Many  Patient will  Patient will
of infection chemotherapy maintain an 2. Teach patient and  Hand hygiene helps maintain an
 Receiving drugs are designed infection free family neutropenic prevent infection infection free
antineoplastic to target this type state during precautions to and prevent transmission state during
therapy of rapid cell growth. shift. perform like of microorganisms. shift.
  Large  Patient will have handwashing  Patient will h
exposure of  Chemotherapy no episodes of frequently before no episodes
tissues and treatments can’t active bleeding entering and active bleedi
extensive differentiate during shift. leaving the room. during shift.
dissection between cancer  Patient will  Patient will
across vascular cells and healthy maintain food 3. Inform parents  Prevents a highly maintain foo
distributions. cells resulting in safety and and child to avoid susceptible child to safety and
 Weakness harming healthy nutrition during exposure to people acquire an infection. nutrition dur
  cells, as well as shift. with upper shift.
cancer cells.   respiratory infectio  
n or any illness.
These medications Long term: Long term:
slow down the 4. Using of protective  Prevents transmission of
body's immune After 3 days of gear such as mask a microorganism to a After 3 days of
system and at the nursing and gown when compromised immune nursing
same time reducing intervention, the appropriate, system during intervention, the
inflammation. patient will be able providing a private chemotherapy patient was be a
to: room, monitor for to:
any signs and
 Continue to symptoms of  Continued to
maintain an infections. maintain an
infection free infection free
state. state.
5. Monitor affected  Suppression of bone
 Continue to limb for bleeding, marrow and  Continued to
have no inflammation of platelet production have no
episodes of the membranes. places pt. at risk for episodes of
active bleeding spontaneous bleeding. active bleedi
during. during.
 Continue to 6. Implement  Continued to
maintain food measures to  Fragile tissues and maintain foo
safety and prevent tissue altered clotting safety and
nutrition. injury or bleeding. mechanisms increase the nutrition.
  risk of haemorrhage  
following even minor
trauma.

Dependent:

7.  Administer  Pharmacologic methods

antineoplastic is vital in cancer therapy
medications as
ordered
Collaborative:

8. Ensure that patient  A good, well balanced

is well nourished diet will aid in healing
by collaborating and good immunity.
with a nutritionist Protein placed meals or
for the patinet’s drinks will aid in this.
proper diet. Raw foods often carry
  bacteria, which could
  cause infection.
 ASSESSMENT DIAGNOSIS RATIONALE PLANNING IMPLEMENTATION RATIONALE EVALUATION
Independent   GOAL MET
Short term:     Short term:
Subjective data: Impaired physical The tumor causes
After 8 hours of nursing  Assess the strength to  To provide data on After 24 hours of nursing
“Di ko po nailalakad ang mobility related to decreased movement intervention, the patient perform ROM to all extent of any physical intervention, the patient
right leg ko tska will be able to: joints problems was able to:
musculoskeletal in the affected arm or
nahihirapan po ako  Demonstrate  Assess the need for  To avoid weight  Demonstrate
gumalaw.” as verbalized damage as manifested leg or nearby joint. measures to increase assistive devices bearing measures to increase
by the patient mobility  Demonstrate use of   mobility
by inability to bear Patients may limp
   Uses safety measures assistive devices  To maintain or  Uses safety measures
Objective data: weight on the affected because of a tumor in to minimize potential   improve an to minimize potential
for injury   individual’s for injury
 Xray– showed 5x4x4 cm leg the leg or near the
    functioning and  
lesion in the proximal
  knee. Bones affected    Provide a safe independence to Long term:
metaphyseal area of
by osteosarcoma are Long term: environment facilitate participation After 3 days of nursing
the R tibia
After 3 days of nursing  Encourage participation and to enhance intervention, the patient
 Could not bear weight
weakened, and they intervention, the patient in recreational overall well-being was able to:
on the affected leg
may be more likely to will be able to: activities (watching    
 Presented with a limp
  TV, reading  To reduce risk for falls  Perform physical
 Could not flex more fracture or break.  Perform physical newspapers, etc.).   activity within limits
than 30 degrees
  activity within limits    To improve the of disease
actively and passively
of disease  Execute active assistive patient's sense of self  Minimize
 Unable to perform
 Minimize ROM exercises to all control and help in complications of
resisted
complications of extremities within reducing social immobility
flexion/extensions
immobility limits of disease isolation.  
 Active/passive ROM of
   Turn and position  
the right ankle caused
  patient every 2 hours.  To maintain muscle
pain
  strength
 Unable to resist
 
extension of the toes
 To promote circulation
and ankle
and relieve pressure