ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective
Masakit talaga ang
tahi ko. Nahihirapan
ako gumalaw. Siguro
nasa 6(10 highest)ang
sakit nia! as
verbali"e# b the
patient.
$bjective
%&estlessness
%'acial mask o( pain
%)rritabilit
%*ale
%+S taken as (ollows,
-*, 110/80 mmHg
-., 36.8
o
C
*&,/0
&&,11
2cute pain
relate# to
post3op
surgical
incision
Short3term 4oal,
2(ter 5hours o(
nursing intervention6
the client7s pain will
be lessene#
%$bjective,
2(ter 8 minutes6 the
client will verbali"e
the characteristic
an# location o( pain.
%a(ter 10 minutes
client will be able to
per(orm pain
management such
as #eep breathing
techni9ue
:ong3term 4oal,
%2(ter ; #as o(
nursing intervention
the pain in the
incision site will be
relieve#
%.each o( non3
pharmacologic
techni9ues such
as back massage
an# #eep
breathing
techni9ue.
%*er(orm the
comprehensive
assessment o(
pain to inclu#e
location6
characteristics6
onset6 #uration6
9ualit6 intensit
or severit an#
precipitating
(actors o( pain.
%*rovi#e optimal
pain relie( with
#octor7s
prescribe#
analgesics.
%Monitors
client7s +S
%.he use o( non3
invasive pain
relie( measures
can increase the
release o(
en#orphins an#
enhance the
therapeutic
e<ects o( pain
relie(
me#ications.
%*ain is
subjective
e=perience an#
must be
#escribe# b the
client in or#er to
plan e<ective
treatment.
%>ach client has
a right to e=pect
ma=imum pain
relie(.
%2llows therapist
to un#erstan# a
patient7s
phsiologic
%.he client7s pain was
lessene#
%.he client was able
to per(orm #eep
breathing e=ercise.
%.he client was able
to verbali"e6
characteri"e an#
locate the pain.
%.he client7s +S were
monitore#.
status an# is
help(ul in
#etermining
appropriate
goals.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective
Masaki pa #in
ang tahi ko
hanggang
ngaon! as
verbali"e# b
the patient.
$bjective
3 &estlessness
3'acial mask o(
pain
3*ale
looking(sclera
an# lips)
3+S taken as
(ollows,
-*,90/60 mmHg
-., 36.0
o
C
*&,50
&&,;;
2cute pain
relate# to
post3op
surgical
incision (NS?)
Short3term 4oal,
2(ter 0hours o(
nursing
intervention6 the
client7s pain will
be lessene#
:ong3term 4oal,
2(ter ; #as o(
nursing
intervention the
pain in the
incision site will
be relieve#
1.) .each o( non3
pharmacologic
techni9ues such
appling o( col# an#
warm compress.
;.) *er(orm the
comprehensive
assessment o( pain to
inclu#e location6
characteristics6
intensit or severit
an# precipitating
(actors o( pain.
@.) >ncourage patient
to eat (oo#s rich in
protein an# vitamin A.
0.) *rovi#e optimal pain
relie( analgesics as
prescribe# b the
1.) .he use o( non3
invasive pain relie(
measures can
increase the release
o( en#orphins an#
enhance the
therapeutic e<ects o(
pain relie(
me#ications.
Aol# compress will
cause numbness the
a<ecte# site6
there(ore the patient
pain will be lessene#
an# hot compress
(acilitate circulation o(
the bloo#.
;.) .o know the e=act
location o( the pain in
or#er to plan e<ective
treatment.
@.) *rotein rich (oo#s
.he planning was
(ull met as the
patient
verbali"es lesser
pain to the
a<ecte# area6
was able to
verbali"e6
characteri"e an#
locate the pain.
phsician (acilitate tissue repair
an# vitamin A is (or
(aster woun# healing.
0.) .o #ecrease# the
pain o( the patient to
the a<ecte# site.
Cues Nursing
Diagnosis
Expected Outcoes Nursing Inter!ention Rationa"e #$it% resources& E!a"uation
Su'(ecti!e)
Masakit ung
dito ko
(chest)..mga 6
ung rate
O'(ecti!e)
Chest !ain
"#ser$ed
e$idence o%
!ain.
&/' taken(
)em!( 38.6
*+1,0/80
mmHg
--( 1.c!m
+-( ./ #!m
01cute !ain
re2ated to
in3uring
agents(!h4sica2)
S%ort ter)
1%ter 3 hours o%
nursing inter$ention
the !atient 5i22 #e a#2e
to(
-e!ort re2ie% o%
!ain.
6o22o5 !rescri#ed
!harmaco2ogica2
regimen7 i%
necessar4.
Long ter)
1%ter 1 da4 o% nursing
inter$ention the !atient
5i22 #e a#2e to(
&er#a2i8e
non!harmaco2ogi
c methods that
Independent)
0+ro$ide com%ort
measures7 9uiet
en$ironment and ca2m
acti$ities
0:nstruct/encourage
use o% re2a;ation
techni9ues7 such as
music thera!4.
Dependent)
0+ro$ide !rescri#ed
medications7 i%
necessar4.
0)o !romote
non!harmaco2ogica2 !ain
management.
0)o distract attention and
reduce tension.
0+romote re2ie% o% !ain.
1%ter 3 hours o%
nursing inter$ention7
the !atient 5as a#2e to(
0&er#a2i8e minimi8ed
!ain.
0+er%orm re2a;ation
techni9ues 5e22
0&er#a2i8e re2ie% o%
!ain
!ro$ide re2ie%.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
'u#3ecti$e (
sumasakit ang
2a2amunan ko
+ain sca2e 8/10 as
$er#a2i8ed #4 the
c2ient
"#3ecti$e(
:rrita#i2it4
6acia2 <rimace
-educe
interaction to
!eo!2e
-est2essness
*io!s4 resu2t
(naso!har4ngit
is)
Chronic !ain re2ated
to in%ection o% the
!har4n; (!har4ngitis)
as mani%ested #4
:rrita#i2it4
6acia2 grimace
-educe
interaction to
!eo!2e
-est2essness
*io!s4 resu2t
(naso!har4ngit
is)
')<( a%ter 30
minutes o% nursing
inter$ention the
c2ient !ain 5i22 #e
2essen %rom the !ain
sca2e o% 8/10 to 6/10.
=)<( a%ter , hours o%
nursing inter$ention
the c2ient>s !ain 5i22
e2iminated.
"#tain c2ient>s
assessment o% !ain
to inc2ude 2ocation7
characteristics7
onset/duration7
%re9uenc47 9ua2it47
intensit47 and
aggra$ating %actors.
"#ser$e non$er#a2
cues/!ain #eha$ior.
+ro$ide com%ort
measures.
?ncourage use o%
)o ru2e out
5orsening o%
under24ing
condition/de$e2o!
ment o%
com!2ication
"#ser$ation ma4
not #e congruent
5ith $er#a2 re!orts
or ma4 #e on24
indicator !resent
5hen c2ient is
una#2e to
$er#a2i8e.
)o !romote non
!harmaco2ogica2
!ain management.
<"1= @AM?)(
1%ter , hours o%
nursing
inter$ention the
c2ient>s !ain 5as
not e2iminated
re2a;ation techni9ue
such as %ocused
#reathing imaging.
Be!endent(
1dminister
ana2gesics
!rescri#ed #4 the
!h4sician
)o distract
attention and
reduce tension
)o 2essen the !ain
Nursing Care P"an
Biagnosis( Aaso!har4ngitis
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
Aahihi4a ako sa #uko2
sa 2eeg ko as $er#a2i8ed
#4 the !atient.
Objective:
0:rrita#i2it4
0)( 38./
o
C
0Con%usion
Bistur#ed #od4
image re2ated to
in%ection
Short-term Goal:
01%ter / hours o%
nursing inter$ention7
the c2ient>s !ain 5i22 #e
2essened
0a%ter 10 minutes c2ient
5i22 #e a#2e to !er%orm
!ain management such
as dee! #reathing
techni9ue
Long-term Goal:
01%ter , da4s o%
nursing inter$ention the
!ain in the incision site
5i22 #e re2ie$ed
Independent:
01ssess
menta2/!h4sica2
in%2uence i%
i22ness/condition on
the c2ient>s
emotiona2 state
Dependent:
0Ci22 administer
anti#iotic as
e$idence #4
doctor>s order
Collaborative:
>*egin
counse2ing/other
thera!ies as soon as
!ossi#2e
)o !ro$ide
ear24/ongoing
sources o% su!!ort
0)he c2ient>s !ain 5as
2essened
0)he c2ient 5as a#2e to
!er%orm dee! #reathing
e;ercise.
Assessent Diagnosis P"anning Inter!ention Rationa"e E!a"uation
Su'(ecti!e)
2agi akong
nauuha5 as
$er#a2i8ed #4 the
c2ient.
O'(ecti!e)
Br4 skin
Ceakness
62uid &o2ume
Be%icit re2ated to
%ai2ure o%
regu2ator4
mechanisms
STG)
Cithin 8 hours7
!atient 5i22
maintain ade9uate
%2uid $o2ume.

LTG)
1%ter 1 da4 o%
nursing
inter$ention the
c2ient 5i22 not
sho5 an4 signs o%
deh4dration
Independent)
1. Monitor $ita2
signsD note changes
in #od4 tem!erature.



,. Monitor :/"



3. ?ncourage
increase in %2uid
intake and
consum!tion o%
%oods high in %2uid
content.
E. +ro$ide skin and
mouth care7
massaged skin7 and
a!!2ied emo22ients
as necessar4.
Dependent)
/. 1dministered :&
%2uids as ordered
1. :ncreased H- a2ong 5ith
decreased *+ and e2e$ated
tem!erature is !resent in
conditions 5ith %2uid $o2ume
de%icit.
,. Becreased urinar4 out!ut
ma4 re9uire aggressi$e %2uid
re!2acement.
3. -e2ie$es thirst and aids in
#od4 %2uid re!2acement.
E. -egu2ar skin and mouth
care re2ie$es dr4ness and
discom%ort. =ight massage
!romotes circu2ation. @se o%
emo22ients and mi2d soa!s
!romotes good h4giene and
com%ort 5ithout e;cessi$e
dr4ing o% the skin.
/. 62uid re!2acement ma4 #e
re9uired to correct %2uid
$o2ume de%icit.
<oa2 Met
1%ter 1 da4 o%
nursing
inter$ention7 the
!atient 5as a#2e to(
Maintain
ade9uate %2uid
$o2ume as
mani%ested #4
moist skin.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
'u#3ecti$e(
ang init ng
!akiramdam ko as
$er#a2i8ed #4 the
c2ient.
"#3ecti$e(
62ashed skin
Carm to touch
:rrita#i2it4
:ncrease #od4
tem!. 38./
H4!erthermia
re2ated to
in%ection as
mani%ested #4(
:ncrease #od4
tem!erature 38./7
%2ashed skin7
5arm to touch7
and irrita#i2it4
')<(
1%ter 1/ min o%
nursing inter$ention
the c2ient>s tem!. Ci22
decrease %rom 38./ to
3../.
=)<(
1%ter 8 hours o%
nursing inter$ention
the c2ient>s 5i22 #e
%ree %rom %e$er %rom
38./ to 3..
:AB?+?AB?A)
-eassess $ita2 signs
+ro$ide )'* ( i% not
contraindicated).
:ncrease %2uid
intake.
Cra! e;tremities
5/ cotton #2ankets
.
Maintain #ed rest.
B?+?AB?A)
1dminister
!aracetamo2 /00mg
as !rescri#ed #4 the
!h4sician.
-egu2ar tem!.
Monitoring 5i22
identi%4 ade9uate
thermoregu2ations.
)o reduce heat in the
#od4.
)o su!!ort circu2ation
$o2ume and tissue
!er%usion.
)o minimi8e
shi$ering.
)o reduce
meta#o2ic
demand and
o;4gen
consum!tion.
)o %aci2itate %ast
reco$er4.
<oa2 @nmet( a%ter 8
hours o% nursing
inter$ention the
c2ient 5as not %ree
%rom %e$er.
Cues Nursing
Diagnosis
Rationale Expected
Outcomes
Nursing
Intervention
Rationale (with
resources)
Evaluation
Subjective:
Nilalagnat
ang anak
ko as
verbalized
by the
mother.
Objective:
-Increased
body
temerature
-Skin !arm
to touch
-"#S taken:
$em: %&.'
mm(g
)): %&cm
*): +%,bm
-(yerthermi
a related to
in.lammatory
rocess as
evidenced by
an increased
body
temerature
and !arm
skin.
-In.ectious
/gents
-0onocytes
-*yrogenic
1ytokines
-2levated
thermo
regulated
set oint
-Increased
heat
conservation
-Increased
heat
roduction
-32"2)
Short term:
-/.ter %,
minutes o.
nursing
intervention
the atient
!ill
maintain
normal
body
temerature
4ong term:
-/.ter %
days o.
nursing
intervention
the atient
!ill
maintain
vital signs
and normal
laboratory
results.
Indeendent
-0onitor
neonatal5s
condition
-0onitor
vital signs
-*rovide
$S6.
7eendent:
-roviding
the
rescribed
medications.
-$o determine the need
.or intervention and
e..ectiveness o. theray
-$o have baseline data.
-(els in lo!ering do!n
body temerature
-/.ter 8 hours o. nursing
intervention the atient !ill
maintain normal core body
temerature
Assessent Diagnosis P"anning Inter!ention Rationa"e E!a"uation
Su'(ecti!e)
Me3o masakit !a
rin 4ung tahi ko
O'(ecti!e)
Bestruction o%
skin 2a4ers
:n$asion o% #od4
structures
:m!aired skin
integrit4 re2ated to
mechanica2 %actor
due to surger4
'hort term goa2(
1%ter 8 hours o%
nursing
inter$ention7 the
!atient 5i22 #e a#2e
to(
&er#a2i8e %ee2ing
o% increased se2%
esteem and a#2e to
manage situation.
=ong term goa2(
1%ter , 5eeks o%
nursing
inter$ention7 the
!atient 5i22 #e a#2e
to(
Bis!2a4 time o%
hea2ing o% skin
2esions/!ressure
sores 5ithout
com!2ication.
Maintain o!tima2
nutrition/!h4sica2
5e22#eing.
:nde!endent(
1ssess #2ood
su!!24 and
sensation o%
a%%ected area
+eriodica224
remeasure/
!hotogra!h 5ound
and o#ser$e %or
com!2ications
Fee! the area
c2ean/dr47 !re$ent
in%ection7 and
stimu2ate
circu2ation to
surrounding areas
Be!endent(
1dminister ora2
medications7 i%
indicated.
)o e$a2uate
actua2/!otentia2
%or im!airment o%
circu2ation to
2o5er e;tremities.
)o monitor
!rogress o%
5ound hea2ing.
)o assist #od4>s
natura2 !rocess o%
re!air.
1%ter 8 hours o%
nursing
inter$ention7 the
!atient 5as a#2e to(
<ain his se2%
esteem.
1%ter , 5eeks o%
nursing
inter$ention7 the
!atient 5as a#2e to(
Maintain the
c2ean2iness in the
incision site.
+er%orm his dai24
acti$ities 5e22.
)he goa2 5as met.
Cues Nursing
Diagnosis
Expected Outcoes Nursing
Inter!ention
Rationa"e E!a"uation
Su'(ecti!e)
Bi na ako
nakaka2igo
kasi
nanghihina
ako at gusto ko
2ang humiga
as $er#a2i8ed
#4 the c2ient.
O'(ecti!e)
0:m!ro!er
h4giene
0-est2essness
'e2%care de%icit(
#athing/h4giene
re2ated to ina#i2it4
to !ercei$e #od4
!art/s!atia2
re2ationshi! as
mani%ested #4
ina#i2it4 to 5ash
#od4.
'hort term(
1%ter E hours o%
nursing inter$ention
the !atient 5i22 #e a#2e
to(
0&er#a2i8e re2ie% o%
discom%ort
0+er%orm se2%care
acti$ities 5ithin 2e$e2
o% o5n a#i2it4
=ong term(
1%ter 1 da4 o%
nursing inter$ention7
the !atient 5i22 #e
a#2e to(
0Bemonstrate
techni9ues/2i%est42e
changes to meet se2%
care needs
:nde!endent(
0+ro$ide non
!harmaco2ogica2
techni9ues 2ike
massage and
thera!eutic
communication.
0Bemonstrate
the !ro!er 5a4s
o% doing !ro!er
#athing and
h4giene
!ractices.
0+ro$ide
additiona2 hea2th
teaching a#out
#athing and
h4giene
techni9ues.
0Aon!harmaco2ogica2
techni9ues !ro$ide
re2ie% o% discom%ort.
)hera!eutic
communication
!ro$ides %aster re2ie% o%
discom%ort.
0)o enhance 2earning
ski22s and de$e2o! the
!s4chomotor ski22s o%
the c2ient.
0)o gi$e the c2ient a
dee!er understanding
a#out her h4giene
1%ter E hours o%
nursing
inter$ention the
!atient 5as a#2e
to(
0-e!ort re2ie% o%
discom%ort/
01!!24 the
!ro!er 5a4s o%
good h4giene.