ASSESSMENT NURSING PLANNING INTERVENTIONS NURSING

DIAGNOSIS RESPONSIBILITY
Subjective:  Acute pain related to Short-Term: Independent After 2 hours of continuous
“Medyo masakit pa din yung multiple injury and After 2 hours of continuous nursing care interventions,
mga sugat ko” as verbalized abrasions nursing care interventions,  Accept client’s the client was able to
by the patient. the patient will be able to description of pain. verbalize relief of pain. As
verbalize relief of pain. As Acknowledge the pain manifested by:
Pain scale of 5/10 manifested by: experience and convey  Pain scale of 3/10 (With
 With 1 being no pain acceptance of client’s 1 being no pain and 10
Objective: and 10 being severe response to pain. being severe pain)
 Guarding behavior pain, the patient’s  Less facial mask of pain
towards his hands and pain would be <5  Encourage the client to
legs  Less facial mask of discuss problems related
 Facial Mask of pain pain to current condition
 Vital Signs:
BP: 130/110  Move patient slowly and
PR: 79 deliberately
RR:16
Temp: 36.5
 Encourage use of these
 Lab Test: techniques:
(+) CBC with Platelet  Potential for injury  Distraction  Hydrated
Count RBC count related to potential  Maintaining adequate techniques
(-) H&H formation of venous hydration GOAL IS FULLY MET
(-) UE thrombi  Relaxation exercises,
(+) Cranial CT Scan breathing exercises,
(-) Chest X-ray Long-Term: and music therapy
(-) X-ray T-cage After being admitted in the
hospital, nursing care  Encourage client to
intervention will be applied eliminate additional
at home by: stressors or sources of
 Continuously taking discomfort whenever
home medication. possible.
 Cleaning the wound
properly.
  Avoid hazardous
activities  Instruct client to have
 Eat healthy foods rest periods to
 Increase of fluid facilitate comfort,
intake sleep and relaxation

 Instruct patient to refrain

from excessive exertion,
such as:
 Crying
 Coughing
 Straining
 Blowing the nose and
 Sleeping on the
injured side

Dependent

 Administer mefenamic
acid 500 mg 1 capsule
every 6 hours
 Giving IVF Normal
Saline 30 ml/kg within 30
minutes, followed by 70
ml/kg in the next 2.5
hours

ASSESSMENT NURSING PLANNING INTERVENTIONS EVALUATION

DIAGNOSIS
 Subjective: Decreased intracranial Short-Term: Independent Goal was fully met
“Nahihilo ako pag umuupo adaptive capacity related to After 8 hours of nursing
ako” as verbalized by the injury with cerebral edema interventions, the patient will  Assess neurological After 8 hours of nursing
patient. maintain an optimal cerebral status according to GCS- interventions, the patient
tissue perfusion as evidenced pupil size, reaction and maintained an optimal
Pain scale of 5/10 by ICP less than 10 mmhg; symmetry to light; speech cerebral tissue perfusion as
GCS within normal. and thought processes; evidenced by ICP less than
Objective: motor sensory signs and 10 mmHg; GCS within
 vomiting Long-Term: reflexes normal; no vomiting noted
 decreased pupil After admitting in the and improved pupil
activity hospital. The patient should  Evaluate presence or reactivity.
apply this following nursing absence of protective
intervention, to be able to reflexes (swallowing,
avoid certain dizziness: gagging, blinking and
coughing)
 Avoid sudden changes in
position.  Elevate head of the bed
30 degrees and keep head
 If the person is thirsty, in neutral alignment.
have him or her drink
fluids.
 Avoid valsalva maneuver
 Avoid bright lights.
Dependent:

 Administer Mannitol 100

ml every 6 hours