ASSESSMENT DIAGNOSI PLANNIN INTERVENTION RATIONALE EVALUTAION

S G
Subjective: Impaired After 8 hours A-Assess degree of immobility A-Patient may be restricted by self- After 8 hours of Nursing
physical of Nursing produced by injury/ treatment and view/self- perception out of proportion with Intervention the patient was
Objective: mobility r/t Intervention note patient’s perception of actual physical limitations, requiring able to:
Neuromuscular the patient immobility. information/interv entions to promote
skeletal will able to: progress toward wellness. a. Cooperate with the
Limited ROM  Slowed
impairment. B-  Instruct patient in/assist with student nurse in treatment
movement   Inability to
perform gross/ fine motor a. Cooperate B-Increases blood flow to muscles and bone regimen and safety
skills.   Gait changes  with the C- active/passive ROM exercises of to improve muscle tone, maintain joint measures.
Difficulty of turning student nurse affected and unaffected extremities. mobility; prevent contractures/atro phy and
in treatment calcium resorption from disuse. b. Partially participate in
regimen and ADLs and desired activities
D-  Provide footboard, wrist splints,
safety C-Useful in maintaining functional position of such as eating, maintenance
trochanter/ hand rolls as appropriate.
measures. extremities, hands/feet, and preventing of proper hygiene.
complications (e.g., contractures/ foot drop).
E- Assist with/encourage self-care
b. Participate
activities (e.g., bathing, shaving).
in ADLs and D- Improves muscle strength and circulation,
desired enhances patient control in situation, and
activities such F- Place in supine position periodically
promotes self- directed wellness.
as eating, if possible, when traction is used to
maintenance stabilize lower limb fractures.
E- Reduces risk of flexion contracture of hip.
of proper
hygiene. G- Provide/assist with mobility by
means of wheelchair, walker, crutches, F-Early mobility reduces complications of bed
and canes as soon as possible. Instruct rest (e.g., phlebitis) and promotes healing
in safe use of mobility aids. and normalization of organ function.
Learning the correct way to use aids is
important to maintain optimal mobility and
H- Encourage increased fluid
patient safety.

intake to 2000–3000 ml /day

G- Keeps the body well hydrated, decreasing
(within cardiac tolerance),
risk of urinary infection, stone formation, and
including acid/ash juices.
constipation.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUTAION
Subjective: Acute pain After 8 A-Encourage patient to A- Promotes After 8 hours of
r/t hours of verbalize about pain. cooperation from nursing
Objective: inflammation nursing the client. intervention,
and swelling. intervention B- Encourage patient goal met, the
  Pain scale the patient to do deep breathing B- To promote patient was able
8/10   Facial will able to exercises relaxation, decrease to reduce the
Grimace  reduce the perception of pain, pain from level 8
Limited ROM  pain from C- Encourage adequate increase oxygen to level 2 of
Slowed level 8 to rest period circulation. pain.
movement level 2 of
D- Perform non- C-  To promote
pain.
pharmacological relaxation and
interventions such as prevent fatigue.
music therapy and
gentle massage D-  Non-
pharmacological
E- Provide comfort treatments promote
measures such as cold relaxation and
compress and pillows distract perception
to pain.

E- Comfort measures
such as cold
compress relieve
pain and pillows
 reduce tension

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUTAION

Objective: Pain related Short 1. Position the client in a 1.To be After 30mins of
to Term: comfortable position. more Nursing
>Grimace face(+) After 30mins comfortable Intervention
>irritability (+) inflammation 2. Diversion of activities like
>crying >pain of nursing reading books, drawing, 2.To divert the patient
scale as evidence Intervention the coloring etc. attention of
by grimaced patient will: pain. experience :
3. Provide rest, sleep, And >pain scale 4/10
face and >Pain scale 4/10 relaxation. 3.To provide >comfortable
irritability. Comfort. >(-)irritability
>Comfortable 4. Instruct family member to >(-)grimaced face
>Grimaced face(-) eliminate any positive stressor 4.To provide
>irritability (-) or discomfort. rest and GOAL WAS MET.
comfort
5. Administer pain reliever as
per doctor’s advice. 5. To
relieved
pain and
discomfort.
 .

ASSESSMEN DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUTAIO

T N
Objective: Impaired skin Short Term: 1.Assess skin noted color, turgor 1.To established baseline for Providing timely After 8hrs of
>noted integrity After 8hrs. Of sensation describe and measure the intervention. nursing
swelling related to nursing wounds or mass and observed changes. intervention
of the mass presence of Intervention 2. For baseline data. the patient
>irritable swelling at The patient 2.Monitor VS (temp. RR,BP, HR) understand
>itchiness the left hip 3. To make patient comfortable. the health
>skin redness will verbalize 3. Counter Irritation and touch therapy teaching.
understandi 4. Maintain clean and dry skin provides barrier
ng of health 4. Demonstrate good skin hygiene (e.g to infection. Patting skin dry instead of rubbing
teaching. wash thoroughly and pat dry carefully. reduces risk of dermal trauma to fragile skin.

5.Place the patient in comfortable 5. To make more comfortable and

position(right side lying position)
6. Instruct family member to maintain
clean and dry skin preferably soft cloth
such as cotton fabric or t- shirt.
7.Instruct family member to do hand
washing.
8. Administer oxacillin and cefuroxime
minimized the swelling of mass.
6. Skin friction caused by stiff or rough clothes
leads to irritation of fragile skin in- crease risk
for infection.
7. To prevent spreading of bacteria that causes
infection.
(q8) antibiotic as per doctor’s advice.
9. Schedule for I&D and waiting for the
clearance from pediatrician.
8. To lower bacterial growth and minimized
infection by administering antibiotic.
9. To drain the abscess that present in the mass
that
causes infection and pyomyositis.