ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: STG: Dependent:  A successful treatment plan is STG:

 Her skin has been dry and Mr. Romeo will be involved in the  Observe the frequency and built on careful monitoring. Mr. Romeo was involved in the
scaly and her fingernails was making of the bowel program. features of the patient's feces establishment of the bowel
easily broken. on a daily basis.  To improve physiological program.
 Exercise is out, because she As needed, the patient will report function
lacks energy. a need to defecate.  Provide privacy for As appropriate, the patient stated a
 Her scalp hair is dry and euthanasia  To achieve a regular need to defecate.
breaks easily. Her scalp is The patient's hydration and fiber elimination pattern; and an
scaling. consumption will be increased.  Create and carry out a bowel exercise regimen to increase Mr. Romeo increased his intake of
 She walks slowly. routine that is unique to you. abdominal and pelvic muscle fluids and fiber.
The patient will report smooth and tone.
 She has poor appetite and she full stool evacuation. The patient claimed that the stools
lacks of sleep. were easily and completely
Independent:  It can encourage relaxation and
 Her skin is cold to touch. LTG: evacuated.
 Contribute to general hygiene a sense of well-being.
 She has multiple bruises on
and comfort measures.
both forearms and anterior The patient's elimination pattern LTG:
 It can reduce pain.
lower legs, which are in will be within normal ranges. The patient's elimination pattern
 Make use of a foam mattress,
various stages of healing and was within normal ranges.
a bed cradle, or other similar  To sustain normal
tender when touched. The patient will show the process items. physiological functioning, a
Objective: of skin examination. The patient exhibited a technique
prompt reaction to the need to
 Lethargic  Stress the significance of for skin examination.
defecate is required.
 Hypothermia The patient will develop personal
reacting to the need to
 Sleep deprivation behaviors that will allow him or The patient established personal
defecate.  To encourage proper bowel
 Anorexia her to eliminate normally. practices that ensured proper
function
 Fatigue  Teach the patient how to find elimination.
 Brittle public facilities and how to  Massage may aid in the
 Xerosis wear readily detachable stimulation of peristalsis and
 Alopecia clothing when going on trips. the need to defecate.

 Teach the patient how to  to avoid reliance on laxatives.

massage the abdomen once a
day, as well as how to find
and gently massage the
transverse and descending
colons.
 Teach the patient how to use
laxatives and enemas
properly.
 Encourage the patient to use a
bedside commode or to walk
to the restroom.
 Encourage the consumption
of high-fiber meals.
Overuse of laxatives and
enemas can result in fluid and
electrolyte loss, as well as
injury to the intestinal mucosa.
  To encourage a natural
evacuation stance.
 To provide mass for proper
excretion as well as to increase
muscle tone Encourage fluid
consumption of 6–8 glasses
(1,420–1,900 ml) per day,
unless contraindicated, to
maintain normal metabolic
activities.

 To encourage compliance with

 Collaboration: endorsed count calories.

 Assist the patient in

understanding the food
modification plan, working
with a dietician if necessary.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 STG:
Subjective: Constipation would be a symptom of The patient will Identify
"Masakit at nahihirapan akong chronic discomfort. characteristics of pain and pain
dumumi parang may nakalawit na behaviors.
balat dito sa pwet ko" (I've been
having trouble / pain pooping, it The patient will develop pain
seems that there's a skin protruding at management that includes activity
my anus) as verbalized by the and rest, exercise, and medication
patient. regimen that isn’t pain contingent.
Objective: The patient will state and carry out
 Guarding behavior appropriate interventions for relief of
 Restlessness pain.
 Facial mask of pain LTG:
 V/S taken as follows:
The patient will state relationship of
 Temp - 37.2OC
increasing pain to stress, activity, and
 PR - 95
fatigue.
 RR - 20
BP - 130/80
The patient will carry out
resocialization behaviors and
activities
The patient will state importance of
self-care behavior or activities.
Independent
Dependent:
 On a scale of 1–10, rate the
descriptive qualities of pain,
such as location, quality,
severity, and temporal
elements and sources of
relief; pain tolerance;
ethnicity; attitude, and values.
 Change the surroundings to
encourage sleep at the
patient's recommendation.
 Apply heat or cold as
directed.
 Reposition the patient and, if
necessary, use cushions to
splint or support sore regions.
 Create a behavior-oriented
strategy, such as one for
adhering to an activity
schedule.
 Contract with the patient to
enhance the likelihood that
they will follow the pain
treatment strategy devised
with him.
 Administer analgesic pain
medicine in accordance with
the strategy.
 Teach guided visualization,
deep breathing, meditation,
aromatherapy, and gradual
muscle relaxation to patients.
Practice with the patient on a
regular basis, especially
before night.
 Instruct the patient to avoid
meals that interfere with sleep
and to avoid coffee and
alcohol.
 Pay attention to the patient's
account of his or her
 Descriptions of the specifics STG:
of pain will aid in The patient recognized pain features
determining what the patient's and pain behaviors.
objectives are reasonable.
The patient devised pain
 This permits the patient to management strategies that include
take an active role in his or activity and rest, exercise, and a non-
her therapy. pain-related pharmaceutical regimen.
 To lessen or eliminate The patient expressed and carried out
discomfort suitable pain-relieving
 To alleviate muscle spasms LTG:
and relieve pressure on The patient reported a link between
various bodily regions growing discomfort and stress,
exercise, and weariness.
 Behavioral–cognitive
The patient engaged in
interventions can assist
patients in changing learned resocialization activities and
pain behaviors. behaviors.
 A contract is an agreement The patient emphasized the
that can always be referred to significance of self-care behavior or
if the patient attempts to activities.
make decisions that are not in
accordance with the terms of
the plan.
 When a patient wants more
than the plan permits, repeat
the plan's provisions to avoid
overmedicating.
 Purposeful relaxing attempts
typically aid in the promotion
of sleep.
 Caffeine-containing foods
and beverages ingested less
than 4 hours before night may
disrupt sleep. Alcohol
interferes with regular sleep,
especially when consumed
just before bed.
 Listening carefully conveys
to the patient that the nurse is
interested. It also aids in
determining improvement in
pain relief.
 suffering. Allow time for the  Pain-related discomfort may
patient to express his or her hinder the patient from
dissatisfaction. sleeping soundly.

 Every day, ask the patient to  Achieving pain management

report the quality of his or her objectives while maximizing
sleep. patient cooperation

 Collaboration with  To advocate for

Employees and families is nonpharmacologic pain
essential. treatment.

 Allow the patient to employ  To alleviate pain and sadness

alternative pain therapies
typical in his or her culture  Maintaining care that is goal-
(such as acupuncture) as a oriented
substitute or supplement to
western therapy wherever
possible.

 Please refer the patient to a

support group.

 Set up regular
multidisciplinary/family care
conferences.