Magumun, Francesca Abuelos Haven 1

BSN-4B December 18, 2023

Sir Franc Tan
Date and Time FOCUS DATA: Reports of decreased tolerance for activityWalking with a
limp, inability to walk, preoccupation with pain,self/narrowed
12/18/2023 Acute Pain focus,Guarding behavior, leans toward affected side when standing
2:00 to 11:00 pm Altered muscle tone
ACTION: Assess client’s perceptions of pain, and attitude toward
pain and use of specific pain medication, Performed comprehensive
assessment of pain, noting location, duration, precipitating/aggravating
factors, and severity. Asked the client to rate on a scale of 0–10 (or
other scale as appropriate). Accept client’s description of pain.Provide
comfort measures; e.g., backrub, positional and stretching exercises,
therapeutic touch (TT), quiet environment.Instruct in/assist with
relaxation/visualization tech-niques, progressive muscle relaxation,
breathing exercises.Instruct in modification of activities; encourage
correct body mechanics/body posture.
RESPONSE: Client verbalized relieved by pain scale of 4/10
Magumun, Francesca Abuelos Haven 1
BSN-4B December 19, 2023
Sir Franc Tan
Date and Time FOCUS DATA: Biophysical changes/altered physical appearance
ACTION: Discussed situation/encourage verbalization of fears and
12/19/2023 Body Image concerns. Explained relationship between nature of disease
2:00 to 11:00 pm Disturbance and symptoms. Support and encouragd clients, provide care with a
positive, friendly attitude. Encourage family/SO to verbalize feelings,
visit freely/ participate in care.Assist client/SO to cope with change in
appearance; suggest clothing that does not emphasize altered
appearance;e.g., use of red, blue, or black clothing.
RESPONSE: The resident gained controlled with his emotions by
positively coping with the situation,
Quintana, Gazelle T. Abuelos Haven 1
BSN-4B December 20, 2023
Sir Franc Tan
Date and Time FOCUS DATA : Decreased strength/endurance; musculoskeletal
impairment Perceptual/cognitive impairment
12/20/2023 Safety ACTION: Assessed activity limitations, noting presence/degree of
2:00 to 11:00 pm restriction/ability. Encouraged frequent change of position when on
bedrest or chair rest; support affected body parts/ joints with pillows,
rolls, sheepskin, elbow/heel pads as indicated. Provided gentle
massage. Keeped skin clean and dry. Keep linens dry and wrinkle free.
Encouraged deep breathing and coughing. Elevate head of bed as
appropriate. Suggest/provide diversion as appropriate to client’s
condition; e.g., visitors, radio/television, books. Take time to interact
with client, showing interest in his or her life. Instruct in and assist
with active/passive ROM exercises.
RESPONSE: The client is kept being safe from any injuries and
demonstrated behaviors to avoid injuries.
 NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Acute Pain Short Term: Independent Short Term:

“ Masakit yung kaliwang related to After 4 hours of
paa ko as verbalized by Physical factors nursing intervention Assess pain, Helps evaluate GOAL MET
the patient as evidenced by that patient will be noting location, degree of
Reports of pain able to Verbalize characteristics, discomfort After 4 hours of
Objective: 6/10 relief/control of pain. intensity nursing intervention
Appear relaxed, (0–10scale). that patient was
Reports of pain 6/10 able to sleep/rest able to Verbalize
Guarding/distraction appropriately. Auscultate bowel Indicates relief/control of
behaviors, restlessness sounds, note reestablishment of pain. With a scale
Self-focusing passage of flatus. bowel function. of 6/10 Appear
relaxed, able to
Note urine flow Decreased flow sleep/rest
and may reflect urinary appropriately.
characteristics. retention (due to
edema) with
increased

Encourage client Reduction of

to verbalize anxiety/fear can
concerns. promote
Active-listen these relaxation and
concerns and comfort. Reduces
provide support by muscle tension,
acceptance, promotes
remaining with relaxation, and
client and giving may enhance
appropriate coping abilities
information.

Provide comfort
measures; e.g.,
 back rub,
repositioning
(using body
support measures
as needed).

Assure clients that Reduces

position change muscle/joint
will not injure stiffness.
stoma.

Encourage use of
relaxation
techniques; e.g.,
guided imagery,
visualization,
diversional
activities.

Assist with ROM

exercises and
encourage early
ambulation.

Investigate and
report abdominal
muscle rigidity
Collabration:

NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Impaired physical Short Term: Independent Short Term:

mobility related to After 4 hours of After 4 hours of
Objective: decrease nursing intervention Determine functional Identifies the nursing
strength that patient will be ability (0–4 scale) and need for/degree intervention the
impaired able to VERBALIZE reasons for of intervention patient was able
coordination techniques/behavior impairment required. to verbalize
that enable techniques/beha
resumption of vior that enable
activities NoteEmotional/behav resumption of
ioral responses to activities
altered ability.

Plan Activities/visits Can

with adequate rest limit/prevent
periods as necessary. fatigue;
conserve
energy for
continued
Participation.
Encourage Can
participation in limit/prevent
self-care, fatigue;
occupational/ conserve
recreational activities. energy for
continued
participation.

Provide chairs with Facilitates rising

firm, high seats and from a seated
lifting chairs when position.
indicated

Perform initial and Information can

ongoing fall-risk help determine
assessment, client’s potential
including fall history, for falling and
gait and balance identify which
assessment, risk factors can
cognition, use of be modified
mobility adjuncts,
environmental
conditions.

Assist with transfers Prevents

and ambulation if accidental
indicated; show falls/injury,
client/SO ways to especially in the
client with altered
move safely. gait,

Assists client to
Obtain supportive walk with a firm
shoes and well-fitting, step/maintain
nonskid slippers. sense of balance
and prevents
slipping.
Remove clutter,
Reduces risk of
wires/cords, scatter falling/injuring
rugs, and extraneous self.
furniture from
pathways. Keep
floors dry.

Encourage use of Promotes

hand rails in independence in
hallways, stairwells, mobility; reduces
risk of falls.
and bathrooms. Keep
bed height in a low
position.
Facilitates activity,
Review safe use of reduces risk of
injury
mobility
aids/adjunctive
devices; e.g., walker,
braces, prosthetics.

Collabration:

Consult with Consult with

physical/occupational physical/occupati
onal therapists,
therapists, rehabilitation
rehabilitation specialists.
specialists.