ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective Masakit talaga ang tahi ko. Nahihirapan ako gumalaw. Siguro nasa 6(10 highest)ang sakit ni a! as verbali"e# b the patient. $bjective %&estlessness %'acial mask o( pain %)rritabilit %*ale %+S taken as (ollows, -*, 110/80 mmHg -., 36.8o C *&,/0 &&,11

2cute pain relate# to post3 op 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 ; #a s 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.

%.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.

%.he client7s pain was lessene# %.he client was able to per(orm #eep breathing e<ercise.

%*er(orm the comprehensive assessment o( pain to inclu#e location6 characteristics6 onset6 #uration6 9ualit 6 intensit or severit an# precipitating (actors o( pain. %*rovi#e optimal pain relie( with #octor7s prescribe# analgesics. %Monitors client7s +S

%.he client was able to verbali"e6 characteri"e an# locate the pain.

%=ach client has a right to e<pect ma<imum pain relie(. %2llows therapist to un#erstan# a patient7s ph siologic status an# is help(ul in #etermining appropriate goals.

%.he client7s +S were monitore#.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective Masaki pa #in ang tahi ko hanggang nga on! 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 -., 36.0o C *&,50 &&,;;

2cute pain relate# to post3 op surgical incision (NS>)

Short3term 4oal, 2(ter 0hours o( nursing intervention6 the client7s pain will be lessene# :ong3term 4oal, 2(ter ; #a s o( nursing intervention the pain in the incision site will be relieve#

1.) .each o( non3 pharmacologic techni9ues such appl ing 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 @. 0.) *rovi#e optimal pain relie( analgesics as prescribe# b the ph sician

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. @ol# 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.

.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.

?.) *rotein rich (oo#s (acilitate tissue repair an# vitamin @ is (or (aster woun# healing. 0.) .o #ecrease# the pain o( the patient to the a((ecte# site.

Cues 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

Nursing Diagnosis

Expected Outco es

Nursing Inter!ention

Rationa"e #$it% resources&

E!a"uation 1%ter 3 hours o% nursing inter$ention7 the !atient 5as a#2e to( 0&er#a2i8e minimi8ed !ain.

S%ort ter ) 01cute !ain 1%ter 3 hours o% re2ated to nursing inter$ention in3uring the !atient 5i22 #e a#2e agents(!h4sica2) to( -e!ort re2ie% o% !ain. 6o22o5 !rescri#ed !harmaco2ogica2 regimen7 i% necessar4. Long ter ) 1%ter 1 da4 o% nursing inter$ention the !atient 5i22 #e a#2e to( &er#a2i8e non!harmaco2ogi c methods that !ro$ide re2ie%.

Independent) 0+ro$ide com%ort 0)o !romote measures7 9uiet non!harmaco2ogica2 !ain en$ironment and ca2m management. acti$ities 0:nstruct/encourage 0)o distract attention and use o% re2a;ation reduce tension. techni9ues7 such as music thera!4. Dependent) 0+ro$ide !rescri#ed 0+romote re2ie% o% !ain. medications7 i% necessar4.

0+er%orm re2a;ation techni9ues 5e22

0&er#a2i8e re2ie% o% !ain

ASSESSMENT 'u#3ecti$e ( sumasakit ang 2a2amunan ko +ain sca2e 8/10 as $er#a2i8ed #4 the c2ient

DIAGNOSIS Chronic !ain re2ated to in%ection o% the !har4n; (!har4ngitis) as mani%ested #4 :rrita#i2it4 6acia2 grimace -educe "#3ecti$e( interaction to :rrita#i2it4 !eo!2e 6acia2 <rimace -est2essness -educe *io!s4 resu2t interaction to (naso!har4ngit !eo!2e is) -est2essness *io!s4 resu2t (naso!har4ngit is)

PLANNING ')<( 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.

INTERVENTION "#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.

RATIONALE )o ru2e out 5orsening o% under24ing condition/de$e2o! ment o% com!2ication

EVALUATION <"1= ABM?)( 1%ter , hours o% nursing inter$ention the c2ient>s !ain 5as not e2iminated

+ro$ide com%ort measures. ?ncourage use o% re2a;ation techni9ue such as %ocused #reathing imaging. @e!endent( 1dminister ana2gesics !rescri#ed #4 the !h4sician

"#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. )o distract attention and reduce tension )o 2essen the !ain

Nursing Care P"an @iagnosis( Baso!har4ngitis ASSESSMENT Subjective: Bahihi4a ako sa #uko2 sa 2eeg ko as $er#a2i8ed #4 the !atient. Objective: 0:rrita#i2it4 0)( 38./o C 0Con%usion DIAGNOSIS @istur#ed #od4 image re2ated to in%ection PLANNING Short-term Goal: 01%ter / hours o% nursing inter$ention7 the c2ient>s !ain 5i22 #e 2essened INTERVENTION RATIONALE EVALUATION 0)he c2ient>s !ain 5as 2essened 0)he c2ient 5as a#2e to !er%orm dee! #reathing e;ercise.

Independent: 01ssess menta2/!h4sica2 in%2uence i% i22ness/condition on the c2ient>s 0a%ter 10 minutes c2ient emotiona2 state 5i22 #e a#2e to !er%orm !ain management such as dee! #reathing techni9ue Dependent: 0Ci22 administer anti#iotic as Long-term Goal: e$idence #4 01%ter , da4s o% doctor>s order nursing inter$ention the !ain in the incision site Collaborative: 5i22 #e re2ie$ed >*egin counse2ing/other thera!ies as soon as !ossi#2e

)o !ro$ide ear24/ongoing sources o% su!!ort

Assess ent Su'(ecti!e) 2agi akong nauuha5 as $er#a2i8ed #4 the c2ient. O'(ecti!e) @r4 skin Ceakness

Diagnosis 62uid &o2ume @e%icit re2ated to %ai2ure o% regu2ator4 mechanisms

P"anning 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

Inter!ention
Independent) 1.Monitor $ita2 signsD note changes in #od4 tem!erature.

Rationa"e 1. :ncreased H- a2ong 5ith decreased *+ and e2e$ated tem!erature is !resent in conditions 5ith %2uid $o2ume de%icit. ,. @ecreased urinar4 out!ut ma4 re9uire aggressi$e %2uid re!2acement. 3. -e2ie$es thirst and aids in #od4 %2uid re!2acement.

,.Monitor :/"

3.?ncourage increase in %2uid intake and consum!tion o% %oods high in %2uid content.

E!a"uation <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.

E. -egu2ar skin and mouth care re2ie$es dr4ness and E.+ro$ide skin and discom%ort. =ight massage mouth care7 !romotes circu2ation. Ase o% massaged skin7 and emo22ients and mi2d soa!s a!!2ied emo22ients !romotes good h4giene and as necessar4. com%ort 5ithout e;cessi$e dr4ing o% the skin. Dependent) /. 1dministered :& %2uids as ordered /. 62uid re!2acement ma4 #e re9uired to correct %2uid $o2ume de%icit.

ASSESSMENT
'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./

DIAGNOSIS
H4!erthermia re2ated to in%ection as mani%ested #4( :ncrease #od4 tem!erature 38./7 %2ashed skin7 5arm to touch7 and irrita#i2it4

PLANNING
')<( 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..

INTERVENTION
:B@?+?B@?B) -eassess $ita2 signs

RATIONALE
-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.

EVALUATION
<oa2 Anmet( a%ter 8 hours o% nursing inter$ention the c2ient 5as not %ree %rom %e$er.

+ro$ide )'* ( i% not contraindicated). :ncrease %2uid intake. Cra! e;tremities 5/ cotton #2ankets . Maintain #ed rest.

@?+?B@?B) 1dminister !aracetamo2 /00mg as !rescri#ed #4 the !h4sician.

Cues

Nursing

Rationale

Expected

Nursing

Rationale (with

Evaluation

Diagnosis Subjective: Nilalagnat ang anak ko as verbalized by the mother. Objective: -Increased body tem erature -Skin !arm to touch -"#S taken: $em : %&.' mm(g )): %&c m *): +%,b m -(y erthermi a related to in.lammatory rocess as evidenced by an increased body tem erature and !arm skin. -In.ectious /gents -0onocytes -*yrogenic 1ytokines -2levated thermo regulated set oint -Increased heat conservatio n -Increased heat roduction -32"2)

Outcomes Short term: -/.ter %, minutes o. nursing intervention the atient !ill maintain normal body tem erature 4ong term: -/.ter % days o. nursing intervention the atient !ill maintain vital signs and normal laboratory results.

Intervention resources) Inde endent -0onitor -$o determine the need neonatal5s .or intervention and condition e..ectiveness o. thera y -$o have baseline data. -(el s in lo!ering do!n body tem erature

-/.ter 8 hours o. nursing intervention the atient !ill maintain normal core body tem erature

-0onitor vital signs

-*rovide $S6. 7e endent: - roviding the rescribed medications.

Assess ent Su'(ecti!e) Me3o masakit !a rin 4ung tahi ko O'(ecti!e) @estruction o% skin 2a4ers :n$asion o% #od4 structures

Diagnosis :m!aired skin integrit4 re2ated to mechanica2 %actor due to surger4

P"anning '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( @is!2a4 time o% hea2ing o% skin 2esions/!ressure sores 5ithout com!2ication. Maintain o!tima2 nutrition/!h4sica2 5e22 #eing.

Inter!ention :nde!endent( 1ssess #2ood su!!24 and sensation o% a%%ected area

Rationa"e )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.

E!a"uation 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.

+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 @e!endent( 1dminister ora2 medications7 i% indicated.

Cues Su'(ecti!e) @i 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

Nursing Diagnosis '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.

Expected Outco es

Nursing Inter!ention

Rationa"e

E!a"uation 1%ter E hours o% nursing inter$ention the !atient 5as a#2e to( 0-e!ort re2ie% o% discom%ort/

'hort term( 1%ter E hours o% nursing inter$ention the !atient 5i22 #e a#2e to( :nde!endent( 0&er#a2i8e re2ie% o% 0+ro$ide non discom%ort !harmaco2ogica2 techni9ues 2ike massage and thera!eutic communication. 0+er%orm se2% care acti$ities 5ithin 2e$e2 0@emonstrate o% o5n a#i2it4 the !ro!er 5a4s o% doing !ro!er =ong term( #athing and 1%ter 1 da4 o% h4giene nursing inter$ention7 !ractices. the !atient 5i22 #e a#2e to( 0@emonstrate techni9ues/2i%est42e changes to meet se2% care needs 0+ro$ide additiona2 hea2th teaching a#out #athing and h4giene techni9ues.

0Bon !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.

01!!24 the !ro!er 5a4s o% good h4giene.

0)o gi$e the c2ient a dee!er understanding a#out her h4giene