ASSESSMENT DIAGNOSIS PLANNING INTERVERTION RATIONALE EVALUATION

After 1 to 2 hours of >monitored vital signs >serve as a baseline data The client’s level of pain
SUBJECTIVE: Acute Pain related nursing intervention >monitor and document >variation of appearance was minimized as
“Nakakaramdam ako to tissue swelling of the client’s feeling of characteristic of pain, noting and behavior of client’s evidenced by decreased
ng kirot sa aking the kidney. pain will be verbal and non-verbal cues pain may present a pain scale from 6 to 3.
kaliwang tagiliran “ minimized/reduced change in assessment
as verbalized by the to a tolerable level. >obtain full description of pain >pain is subjective
patient” from client including location, experience and must be
intensity, duration, describe by client
characteristic and radiation
>Provide comfort measures >To promote relief and
OBJECTIVE: such as use of pillows under wellness.
extremities and periodic
Vital Signs: wound cleaning on affected
BP – 120/80 area.
PR – 87 bpm >Encourage and assist client >Deep breathing
RR – 32 to do deep breathing exercises contribute to
breaths/min exercises. relief of pain
Temp – 37.4
(+)stabbing pain > Teach client and significant >To maximize
left lower quadrant other about the non- opportunities for self-
of the abdomen pharmacologic ways to control over pain
Pain scale- 5-6 lessen the pain. manifestations.
> Instruct client to report any >Only the client can
(+) facial grimace
improvement/exacerbation in judge the level and
pain experience. distress of pain;
the abdomen for bowel pain management
sounds should be a team
approach that
includes the client.
>Administer medications, >To manage the pain of
particularly analgesics, as the client
prescribed.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Risk for infection After an hour of 1. Monitor vital - Indicators of sepsis After an hour of
SUBJECTIVE: related to nurse patient signs for fever. requiring prompt nurse patient
“Nilagyan na ako ng catheter periodic interaction he evaluation and interaction the patient
unang araw ko palang dito catheterization . patient will be able able to verbalized
intervention.
sa ospital.” (As verbalized by
to verbalize 2. Encourage - to maintain renal understanding on how
the paient)
understanding on increase fluid function and prevent to prevent infection.
the health intake development of
teachings given. infection
OBJECTIVE: 3. Emphasize good - Prevents cross-
hand washing contamination;
Vital Signs: technique for all reduces risk of
BP – 120/80 individuals coming acquired infection
PR – 87 bpm in contact with
RR – 32 breaths/min
Temp – 37.4
patient. - reduces risk of
4. Encourage ascending
>Pt. seen with an meticulous infection
indwelling Catheter and
catheter perineal care
- Prevents
connected with 5. Provide sterile or
exposure to
the urine bag freshly laundered
infectious Organisms.
>(+)body linens/gowns.
- Prevents cross-
malaise 6. Monitor/limit
contamination from
>(+) edema in lower visitors, if
visitors.
etremeties necessary.
-Reduces bacteria
7. Administer
present in urinary tract
antibacterial as
and those introduced
ordered.
by drainage system.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Fluid Volume After 8 hours of span 1. Established ® To gain trust & After 8 hours of
“ang bigat-bigat ng excess r/t of care, the rapport. cooperation of patient. span of care, the
pakiramdam ko” (as Compromised patient will be able to 2. Monitored vital ® To monitor patient’s patient able to
verbalized by the regulatory display appropriate signs. over-all status. displayed
patient) mechanism. urinary output. 3. Record accurate ® Accurate I&O is appropriate urinary
intake and output necessary for output.
(I&O). determining renal
function and fluid
OBJECTIVE:
replacement needs and
reducing risk of fluid
Vital Signs: overload
BP – 120/80
4. Weigh daily at ® Daily body weight is
PR – 87 bpm
same time of day, on best monitor of fluid
RR – 32
same scale, with same status.
breaths/min
equipment and
Temp – 37.4
clothing..
5. Assess skin, face, ® Edema occurs
>(+)body and dependent areas primarily in dependent
malaise for edema. tissues of the body, e.g.,
>(+) edema in lower hands, feet, lumbosacral
etremeties area.
6. Limit fluids as
indicated. ® Fluid management is
insensible losses usually calculated to
replace output from all
7. Administer sources plus estimated
medications as ®Given early in oliguric
indicated. phase of Renal Failure in
effort to convert
nonoliguric phase, flush
the tubular lumen of
debris, reduce
hyperkalemia, and
promote adequate urine
volume.
DEX,
SORRY LATE YUNG NCP KO…..
KULANG PA YUNG MGA OBJECTIVES KO…..
PWEDE GA PADAGDAGAN NAMAN
PAKITINGIN NALANG SA P.A NUNG
PATIENT…..PATI SA VITAL SIGNS PAKITAMA
NALANG…. PLZ….. SORRY TALAGA….. TNX…!
WAJ^_^