Name: Levi M.
Concepcion bsn 3a1
ASSESSMENT
icues:
Subjective
“wala mn koy gina buhat dri sa
balay bulak bulak lng” as verbalized
by the patient
“sakit kaayu akng bukton ako
nalang gina pa pa hilot arun
mawala wala ang sakit” as
verbalized by the patient
0 is the lowest and 10 is the highest
with the pain characteristics of
moderate pain
Pain scale: 8/10
Objective
● with facial grimace
● verbal report of pain
● lying on bed
NURSING PLANNING
DIAGNOSIS
Activity intolerance SHORT TERM GOALS:
related to acute pain
in right arm evidenced At the end of the 12 hours of nursing
by pain scale 7/10 interventions, the patient will be able
to:
1. the patient will be
decreased in the pain scale
of 7/10 to a manageable
level of 0/10
2. the feeling of the patient
will at ease
LONG TERM GOALS:
At the end of the 3 days of nursing
interventions, the patient will be able
to:
a. Maintain activity level
within capabilities
b. Free from acute pain
a. verbalized the importance
of activity tolerance
b. The patient will participate
in any kind of activity
tolerance
c. Able to demonstrate the
relaxation skills
d. Verbalized the importance
of medication regimen.
e. Verbalized the cause of
acute pain
NURSING INTERVENTIONS EVALUATION
DEPENDENT
1. Administer Aspirin as a pain reliever SHORT TERM GOALS:
325 -650 mg every 4 hours.
At the end of the 12 hrs of nursing
R: Aspirin is used to relieve mild to moderate
interventions, goal met as evidenced by
pain from conditions such as muscle aches.
INDEPENDENT 1. The patient decreased the pain
scale 7/10 to 0/10 with no
1. Assess the ability to perform adl’s. discomfort.
R: To determine the capacity of the patient LONG TERM GOALS
doing adl’s.
At the end of the 3 days of nursing
2. Assist the patient to do the adl’s interventions, goal met as evidenced by
R: to maximize fatigue and evaluate the
capabilities of the patient.
3. Observe the patient’s response to 2. Positive verbal report of the
activity and document in an Activity nursing interventions.
Chart. 3. Able to do the Adl’s without an
assistant.
R: An Activity chart can help show trends on a 4. There is report of acute pain in
patient’s tolerance to performing ADLs or patient arm
exercise, such as duration, need for 5. The patient verbalized the
supplemental oxygenation, support from staff, ways of improving activity
or pain medication. tolerance.
6. Verbalized the importance of
4. Teach the patient to gradually do activity tolerance.
more active range of motion 7. The patient reports his activity
exercises while in bed. Start with tolerance every day.
sitting from the bed into the chair
for 30 mins, standing and walking
for a minute or two, and sitting
again.
R: It is important to promote exercises to
prevent muscular decline and improve energy
levels
 5. Encourage the patient to perform
deep breathing exercises at least 3
times a day.

R: Deep breathing exercises, also known as

thoracic expansion exercises and make you
relax.

6. Health teaching the importance of

Activity tolerance.

R: able have the knowledge of a certain thing

to do to increase activity tolerance level.

7. Health teaching what is the cause

of acute pain
R: In order to avoid acute pain caused by
Activity Intolerance.

8. Encourage the patient to drink at

least 10 glasses of water per day.
R: To have healthier and good blood flow.

9. Promote rest and comfort to

R: To conserve energy