Cues Nursing Goals and Nursing interventions Rationale Evaluation

Diagnosis Objectives
Subjective: Long Term: Independent:
Chronic pain After 3 days of -Provide comfort measures To promote relief
- Patient related to nursing such as use of pillows under and wellness.
verbalized: abdominal intervention the extremities and periodic
“Sumasakit dito ko cramps patient will be wound cleaning on affected Deep breathing
(referring to secondary to able to experience area. exercises
abdomen), parang non-ulcer gradual reduction / - Encourage and assist client contribute to relief
may naninigas sa dyspepsia relief of pain from to do deep breathing of pain
loob…dati pa to a pain scale of 6 to exercises.
eh, medyo bata at least 3. - Teach client and significant To maximize
bata pa ko.” other about the non- opportunities for
pharmacologic ways to self-control over
Objective: Short Term: lessen the pain. pain
-Pain scale of 6 for After series of - Instruct client to report any manifestations.
abdominal pains. nursing improvement/exacerbation in
- Exhibits facial interventions, the pain experience. Only the client
grimace upon patient will be - Encourage verbalization of can
palpation of the able to: feelings about the pain. judge the level
abdomen. - Verbalize - Physical Examination: and
-Shows signs of reduction/ Periodic auscultation of the distress of pain;
Irritability relief of pain in the abdomen for bowel sounds pain management
- Restlessness abdomen. Inspection and Palpation for should be a team
- Feel and palpate masses and tenderness. approach that
Vital Signs: abdomen includes the
BP – 120/80 without facial Dependent: client.
PR – 87 bpm grimace and - Administer medications,
RR – 32 moaning. particularly analgesics, as Necessary for
breaths/min - Recite and prescribed. management of
Temp – 37.4 demonstrate some - Assist with underlying and
non- laboratory/diagnostic studies possible
pharmacologic as indicated. (e.g., abdominal complications.
ways to lessen
X-ray)
pain.
 Cues Nursing Goals and Nursing interventions Rationale Evaluation
Diagnosis Objectives
Subjective: Long Term: Independent:
Acute pain After 8 hours of - Provide comfort measures To promote relief
- Patient related to nursing such as use of pillows under and wellness.
verbalized: “Ang immobility / interventions, the extremities and periodic
sakit nun (pointing improper patient will be wound cleaning on affected
to left lower leg)... positioning able to experience area. Deep breathing
kumikirot!” gradual reduction / - Encourage and assist client exercises
relief of pain from a to do deep breathing contribute to relief
Objective: pain scale of 8 to at exercises. of pain
- Pain scale of 8 for least 4. - Encourage mobilization of
pain felt at the left the left lower extremity. Assist
lower leg. Short Term: with ROM exercises. To promote
- Exhibits facial After series of - Discuss with client and circulation and
grimace and nursing relatives the importance of prevent excessive
moaning upon interventions, the proper positioning and tissue pressure
movement of the patient will be mobilization.
left lower leg. able to: - Teach client and significant
-Shows signs of - Verbalize other about the non- To maximize
Irritability reduction/ pharmacologic ways to opportunities for
- Restlessness relief of pain. lessen the pain. self-control over
-Physical - Move her left - Instruct client to report any pain
immobility lower improvement/exacerbation in manifestations.
extremity pain experience.
Vital Signs: without facial - Encourage verbalization of  Only the client
BP – 120/80 grimace feelings about the pain. can
PR – 87 bpm - Recite and judge the level
RR – 32 demonstrate some Dependent: and
breaths/min non-pharmacologic - Administer medications, distress of pain;
Temp – 37.4 ways to lessen particularly analgesics, as pain management
pain. prescribed. should be a team
- Have normal approach that
respiratory rate. includes the
client.
 Cues Nursing Goals and Nursing interventions Rationale Evaluation
Diagnosis Objectives
Objective: Excess Fluid Long Term: Independent:
- Restlessness Volume related After 3 days of -Assist in periodic positioning To prevent
- Irritability to impaired nursing every 2 hours. pressure ulcers
-Presence of venous return intervention, the -Monitor I&O and amount of
edema on lower secondary to patient will exhibit fluid intake from all sources To monitor kidney
extremities immobility decreased edema and calculate fluid volume function and fluid
-Taut, shiny skin on on lower imbalance. retention
lower extremities extremities and - Periodically wash between
-Fluid intake stabilize fluid skinfolds and dry carefully. To prevent injury
greater than output volume I&O. -Protect edematous and promote
extremities from injury. wellness
Vital Signs: Short Term: -Relate causative factors
BP – 120/80 After 8 hours of affecting fluid retention. To impart
PR – 87 bpm nursing - Teach client and relatives knowledge
RR – 32 intervention, the about importance of proper regarding present
breaths/min patient will be able positioning and keeping condition
Temp – 37.4 to: edematous feet elevated and
-Identify causative clean. To promote
factors affecting circulation and
fluid retention. Dependent: prevent excessive
-Identify dietary - Administer Medications. tissue pressure
intake and habits
that contribute to
fluid retention.