ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: masakit Short term: > Assess and record > Knowing the client's Short term: clients report
yung tyan ko rated  Clients express pain the location and perception and reaction to the pain to 4 over 10 after
as8 over 10 diminished or duration of pain. pain as an effective basis for giving a analgesic as
disappeared. further intervention. ordered by the physician.

Objective: >Adjust the position of > Reduce emphasis that can

Grimacing facial the fun. cause pain.
expressions.
 Tenderness
in the abdomen. 3. Observation of vital >Can be changed by pain and
signs. an indicator to assess the
state of development of the
disease.

Nursing
Diagnosis:Chronic 4. Encourage clients to > It can help to relax the
pain related to an relax deep breath. muscles so that the supply of
emphasis on O2 to the tissue smoothly so
retroperitoneal as to reduce pain.
organs

5. Encourage clients >Helps block pain stimuli that

perform massage are not perceptible to the
around the painful area. brain.

6. Management of
analgesic drug
 administration
according to the
program so that the
pain can be reduced /
lost.

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Short term: >Assist with self-care >Weakness may make ADLs Short term
Objective needs when indicated; difficult to complete or place the
Report improved keep bed in low position, patient at risk for injury during Reported improved
Nursing sense of energy. pathways clear of activities. sense of energy.
Diagnosis:Fatigue furniture; assist with
related to Altered Perform ADLs and ambulation. Performed ADLs and
body chemistry: participate in participate in desired
side effects of pain desired activities at >Monitor physiological >Tolerance varies greatly activities at level of
and other level of ability. response to activity depending on the stage of the ability.
medications, such (changes in BP, heart disease process, nutrition state,
as chemotherapy and respiratory rate). fluid balance, and reaction to
therapeutic regimen.

>Poorly managed cancer pain

>Perform pain can contribute to fatigue.
assessment and provide
pain management.
>Presence
>Provide supplemental of anemia and hypoxemia redu
oxygen as indicated. ces O2available for cellular
uptake and contributes to
fatigue.

ASSESSMENT EXPLANATION OF PLANNING INTERVENTION RATIONALE EVALUATION

PROBLEM
Subjective Short term Short term
Objective Long term Long term