Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain After 4 hours of - Assess the - Knowing the Goal Met. After 4
“masakittalaga related to disease nursing level of pain, level of pain hours of nursing
tong process as intervention, the location and that is felt so intervention, the
nararamdamanko evidenced by client will report scale of pain, it can help client reports that
” as verbalized non-verbal cues that pain is perceived determine pain is relieved
by the patient. such as (+) relieved and client. appropriate and controlled.
guarding and controlled. interventions.
facial grimace.
- Changes in
- Observation vital signs,
Objective: of vital signs especially
- Guarding every 8 hours. temperature
behavior, and pulse rate
protecting is one
body part indication of
- (+) facial increased pain
grimace experienced
- (+) irritability by the client.
Vital Signs taken - Instruct client
as follows: to perform - Relaxation
BP=130/80 relaxation techniques
T=36.9 techniques can make the
P=88 client feel
R=24 comfortable
and a little
distraction to
divert the
attention of
clients to pain
so that they
 can help
- Provide a children
comfortable reduce the
position. pain.

- a comfortable
position to
- Collaboration avoid an
of analgesic emphasis on
medication. the area of
injury pain.

- Analgesic
drugs block
the pain
receptors so
that the pain
cannot be
perceived.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Activity After 8 hours of -Monitor - To obtain Goal Partially

“Hindi Intolerance relat nursing vital/cognitive baseline Met. After 8
akomakagalawngma ed to general interventions the signs, watching parameters. hours of nursing
weakness, client will for changes in interventions the
ayos,
imbalance demonstrate a blood client was able
kasimasakitangtyan between supply decrease in pressure, heart to demonstrate
ko” as verbalized by and oxygen physiological and respiratory a decrease in
the patient. demand. signs of rate; note skin physiological
intolerance pallor and/or signs of
(e.g., blood cyanosis, and intolerance
pressure remain presence of (e.g., blood
within confusion. pressure remain
client’s normal -Determining the within
range). -Determining the cause can help client’s normal
Objective: cause of range).
determine
- Paleness intolerance
intolerance.
- Warm and dry activity and
skin determine
- Generalized whether the
cause of the
 weakness physical,
Vital Signs taken as psychological /
follows: motivation. -Prolonged
bedrest can
BP=130/90
-Assess the contribute to
T=37.2 suitability of activity
P=83 activity and rest intolerance.
R=24 every day.
-Provides
- Evaluate comparative
current baseline.
limitations/degre
e of deficit in
light of usual
status.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Anxiety related to After 24 - Assess - Prelimina Goal
“nanghihinaako, Threat to or change hours of the level ry data Partially
natatakotakosapwedengmangyarisakal in health status nursing of of Met. After
[progressive/debilit
agayanko” as verbalized by the patient. interventi anxiety, anxiety 24 hours
ating
on, the the is of nursing
disease, terminal
illness], interaction patient factors necessar interventi
patterns, role will that y to on, the
function/ verbalize influence determin patient
Objective: status, awareness the onset e the was able
- Pallor environment of feelings of client’s to
- Cyanosis [safety], economic anxiety. level of
of anxiety. verbalize
- Difficulty of breathing status. anxiety awareness
- Generalized weakness and the
of feelings
Vital Signs taken as follows: factors
of anxiety.
BP=130/90 affecting
T=37.2 it can be
P=83 seen that
R=24 the nurse
- Encourag can
e clients minimize
to / prevent
express clients
their from
feelings, influentia
fears and l factor.
perceptio - Presence
ns. and
readines
s of
nurses in
handling
/
accompa
- Assess ny client
the during
client’s the
expectati period of
ons to anxiety
treatmen can help
t and clients to
care. fulfil a
- Understa sense of
nd the security
client’s so as to
perceptio reduce
n of anxiety.
stressful - The
situations presence
. of the
family
can
provide
mental
support
to
clients.
- Relaxatio
n
techniqu
es can
reduce
stress
arising.