Assessment Diagnosis Planning Interventions Rationale Evaluation

SUBJECTIVE: Acute pain related to Within 4 hours of • Establish • To gain trust After 4 hours of
heartburn nursing interventions rapport of the client nursing interventions
"Sige magsakit akong and health teachings • Assess for • to and health teachings,
dughan day. Murag the patient will: vital signs and differentiate the patient was free
gitusok2 ug usahay • Remain free symptoms of angina pain from pain, maintains
kabuhiun ko” as from pain pain such as from pain stable vital signs, and
verbalized by the • Maintain increased related to relaxed body
client. stable vital blood other causes. posture.
signs. pressure, and • To better • Able to
OBJECTIVE: • Maintain tachycardia. understand verbalize,
relaxed body • Use a pain the certain "Medyo na ok
T- 35.8 posture. rating scale to aspects of the na akong na
PR- 81 assess the patient’s pain bati day"
RR- 15 patient's • To identify the • Rated pain as
BP- 120/60 perception of problem and 3 in the scale
the pain's promote early of 1-10
• cough severity. detection • Goal partially
• Pain scale: • Instruct the • To reduce and met
6/10 patient to minimize the
consult to heartburn
doctor
immediately
when
experiencing
onset of pain.
• Advise the
client to eat
oatmeal and
brown rice
and root
vegetables
 Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective Impaired physical Within 4 hours of • Establish • to build trust After 4 hours of
mobility related to nursing interventions rapport with the client nursing interventions
“Sakit kaayo akong pain and health teachings • Assess the • Level of and health teachings
paa inig maglakaw the patient will: monitor activity the patient was able
ko” as verbalized by • Remain free degree of depends on to be :
the client. from pain joint progression • free from pain
• Maintain inflammation and • Maintained
Objective stable or pain resolution of stable
movement • Advise the inflammatory movement
• Reluctance to and mobility client to process and mobility
attempt maintain bed • It is important • Increased
movement rest throughout all strength and
• Limited range • Encourage phases of function of
of motion adequate fluid disease to affected area
T: 36.5 intake reduce
PR: 80 • Instruct the fatigue Goal met
RR: 20 client to • Helps with
BP: 120/80 maintain excretion of
upright and uric acid and
erect posture decrease
when sitting, likelihood of
standing, or stone
walking. formation
• To maximize
joint function
and maintains
mobility