Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Impaired physical Throughout 8 hours 1 Assist the patient to 1 Repositioning requires Goal met.
Patient voiced ‘nurse mobility related to of independent and reposition every 2 movement, which is Throughout 8 hours
helpful in preventing
mi cannot move left neuromuscular dependent nursing hours. contractures, and
of independent and
leg.’ junction impairment interventions, the promotion circulation, dependent nursing
as evidenced by patient will 2. Demonstrate active which is necessary for interventions, the
Objective patient voicing, participate in ROM exercises to the healing of tissues. patient participated in
Decreased ROM to “nurse mi cannot activities aimed at patient and request activities aimed at
2 Active ROM helps to
affected limb (unable move mi two legs.” improving mobility that they do it to the maintain joint mobility,
improving mobility
to flex, adduct and Decreased ROM to such as: active ROM unaffected limbs muscle strength and such as: active ROM
abduct. affected limb (unable to unaffected limbs, every hour for 5 flexibility. to unaffected limbs,
Skeletal traction to flex, adduct and passive ROM to minutes. passive ROM to
noted to left tibia abduct. Skeletal affected limbs within affected limbs within
3 Affected limbs can
with a gallon weight traction noted to left limitations, isometric atrophy and develop
limitations, isometric
attached. tibia with a gallon exercises, 3 Perform passive contractures, if they are exercises,
1/5 power grade to weight attached. 1/5 repositioning and ROM movements to not mobilized after repositioning and
affected limb and 5/5 power grade to consuming adequate affected limbs within surgery. consuming adequate
to unaffected limbs. affected limb and 5/5 diet. limitations. diet.
4 Isometric movements
Xray confirming to unaffected limbs.
promote movement of
spiral fracture to left Xray confirming muscles without moving
tibia. spiral fracture to left 4 Advocate for the the affected limb. If
tibia. physiotherapist to passive movement causes
facilitate isometric discomfort, that can be
replaced with isometric
exercises.
exercises.

5 Educate patient on 5 A diet with adequate

the benefits to macro and micronutrients
mobility when a is essential to bone
balanced diet is healing.
consumed
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Distured thought Throughout 8 hours 1 Establish a 1 A therapeutic Goal partially met.
Patient voiced “the process related to of independent and therapeutic nurse- relationship will Throughout 8 hours
people dem inna mi neurochical dependent nursing client relationship. foster trust and of independent and
community a prey imbalance secondary interventions, the facilitate openness, dependent nursing
pon wah mi a do pon to schizophrenia as patient’s thought which will make the interventions, the
the internet cause evidenced by patient process will show patient more patient’s thought
dem know say mi a voiced “the people improvement as receptive to process showed
celebrity.” “Mi dem inna mi evidenced by information given by improvement as
bredda put cum inna community a prey decreased frequency the nurse. evidenced by
my food cause him pon wah mi a do pon of delusions as decreased frequency
nuh want mi get fat.” the internet cause evidenced by patient 2 Allow patient to 2 Verbalization of of delusions as
dem know she mi a reducing express feelings and feelings in a non- evidenced by patient
Objective celebrity.” “Mi verbalization of thoughts without threatening reducing
Patient expressed bredda put cum inna persecutory delusions judgement. environment may verbalization of
persecutory my food cause him about brother and help the client to feel persecutory delusions
delusions. nuh want mi get fat.” community members. heard, listened to and about brother.
Patient appeared Patient expressed believe he is a
watchful to his persecutory worthwhile person.
surrounding, delusions. Patient
constantly looking appeared watchful to 3 Administer 3 Haldol is a typical
over his shoulders. his surrounding, prescribed Haldol antipsychotic reduces
constantly looking 5mg PO. the dopaminergic
over his shoulders. (D2) pathways in the
brain thereby
decreasing symptoms
of schizophrenia-
delusions- and help
the patient to think
 clearly.
4 Facilitate the use of
diversional activities 4 Diversional
such as going for a activities may help
walk, paly dominoes, patient to not focus
read a book or watch on delusiona thoughts
television as since their attention
preferred for as long is being redirected.
as possible.
5 Acknowledge that
5 Do not reinforce the situations are real
delusional thoughts. to the patient but it is
not reality. Reality
6 Educate patient on orientation decreases
thought stopping false beliefs.
techniques to use
when delusional 6 Thought stopping
thoughts begin. involves the use of a
command suc has
‘stop’ or a loug noise
such as a hand clap to
interrupt unwanted
thoughts. This
interruption distracts
the individual from
undesirable thinking
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Constipation related Within 8 hours of 1 Ensure patient 1 Adequate water Within 8 hours of
Patient voiced “mi to relaxation of independent and increase water intake intake makes the independent and
nuh too like drink intestinal muscles as dependent nursing to at least 8 cups, asstool softer and easier dependent nursing
water enuh, so mi secondary to side interventions the tolerated for the day.to pass through the interventions the
drink bout 1 or 2 effects of patient will colon, also regain patient experienced a
cups for the day.” anticholinergic and experience a bowel 2Advocate for patient bowel patterns. bowel movement
“Mi prefer cabbage antipsychotic movement without to be prescribed without straining to
and carrot but dat medication (Cogentin straining to pass tool mineral oil 10 ml PO. 2 Mineral oil is a pass tool
don’t come in my and Haldol) as lubricant laxative and
lunch.” “A bout 10 evidenced by patient 3 Advise patient to prevent loss of water
days now mi nuh voiced “mi nuh too increase physical from the colon
dodo” like drink water enuh, activities and thereby softening the
so mi drink bout 1 or exercises such as stool.
Objective 2 cups for the day.” contracting
Hypoactiv bowel “Mi prefer cabbage abdominal muscles 3 Physical activities
sounds. Semi-firm and carrot but dat several times and exercises will
abdomen with slight don’t come in my throughout the day or promote muscle
tenderness. lunch.” “A bout 10 doing jumping jocks movement, which
Patient on Cogentin days now mi nuh as preferred. will increase
and Haldol. dodo.” Hypoactive peristalsis and
bowel sounds, semi- 4 Advocate for circulation in the
firm abdomen with cabbage and carrot to digestive tract, which
slight tenderness. be included in the is needed for easier
patient’s meals, faecal expulsion.
ensure the patient
receives, and eat 4 Cabbage, carrot and
fruits provided. fruits are high in
dietary fibre that
5 Educate patient on draws water into the
the relationship stool making it
between lifestyle larger, softer and
habits and easier to eliminate,
constipation- also speeds up transit
sedentary lifestyle, time.
inadequate fluid
intake and dietary 5 Sedentary lifestyle
fibre. causes decreased
muscle movement
which results in
decrease peristalsis;
while inadequate
fluid and fibre intake
causes a decrease in
the lubrication of
fecal matter in the
colon leading to
constipation
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Ineffective denial Within 8 hours of 1 Develop a 1 A therapeutic Goal met. Within 8
Patient voiced “Min related to fear of independent and therapeutic nurse- relationship will hours of independent
uh insane” “Mi just accepting painful dependent nursing client relationship foster trust and and dependent
deh here because reality of life as interventions, the facilitate openness. nursing interventions,
people inna mi evidenced by patient patient will begin to 2 Covey an attitude the patient has begun
community a watch voiced “Min uh accept that there is a of acceptance 2 An attitude of to accept that there is
mi and mi mother insane” “Mi just deh presence of mental towards the patient. acceptance will a presence of mental
just move mi come here because people condition as promote feelings of condition as
here.” inna mi community a evidenced by patient 3 Identify recent dignity and self- evidenced by patient
watch mi and mi demonstrating an behavior that worth in the patient. demonstrating an
Objective mother just move mi understanding about occurred and discuss understanding about
Patient disregards come here.” Patient the reason for how schizophrenia 3 Seeing the the reason for
mental diagnosis. disregards mental admission when he may have been a connection between admission when he
Patient frowned and diagnosis. Patient identifies his contributing factor, his delusional identifies his
became irritable frowned and became behavior in the past eg, destroying toilet thoughts, hostile behavior in the past
when asked about his irritable when asked and connect it with and thinking he is a behaviour and and connect it with
mental disorder. about his mental signs/symptoms celebrity from schizophrenia aims to signs/symptoms
Patient on Haldol. disorder. associated with France. decrease the use of associated with
schizophrenia. denial. schizophrenia.
4 Do not accept
rationalization and 4 Rationalization and
projections when projections prolong
patient tries to make denial stage that a
excuses or blame problem exists
others for his because of
behavior. schizophrenia.

5 Administer 5 Haldol works by

prescribed Haldol balancing out the
5mg PO. neurochemicals and
 help the patient to
6 Provide continuous think clearly. This
reinforcement by can positively
telling the patient influence the
what you are doing patient’s state of
and why. Eg. Giving mind and help him to
medication. recognize that there
is a presence of
7 Advocate for mental illness.
counselling for the
patient 7 Counseling will
provide patient with
an outlet to overcome
previous trauma
thereby helping the
patient to identify
and avoid triggers.

Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Acute pain related to Within 1 hour of 1 Advocate for 1 Morphine acts directly Within 45 minutes of
C- sticking pain stimulation of independent and Registered Nurse to on the opiod receptors in independent and
administer prescribed the CNS and block
O- 4 days ago nociceptors in the dependent nursing transmission of
dependent nursing
L- abdomen abdomen as interventions, the analgesic Morphine 10 interventions, the
nociceptive signals
mg IM.
D- intermittent evidenced by patient patient will thereby reducing pain patient experienced a
S- 9/10 on numeric complaining of experience a 2 Allow patient to
reduction in pain as
pain scale intermittent sticking reduction in pain as 2 A comfortable position evidenced by patient
assume and remain in a will reduce pain as it
P- lateral position pain in the abdomen, evidenced by patient comfortable position decreases the stimulation
rating pain 3/10 on
with knees flexed rated sae 9/10. Facial rating pain 4/10 or (lateral position with or pain and pressure the numeric pain
A-skin feels tight grimacing, guarding less on the numeric knees flexed), for as receptors scale.
area, patient crying pain scale. long as tolerated
Objective and groaning. 3 Diversional therapy
3 Facilitate the use of may help the patient to
Facial grimacing, not focus on painful
patient guarding area, diversional therapy
stimuli thereby reducing
patient crying and such as allowing
experience
patient to listen to
groaning
music or watching a
movie on mobile 4 Cognitive behavioural
phone, as preferred, for techniques may be helpful
undisturbed periods in pain management
because it helps to change
4 Educate patient about the physical and cognitive
other cognitive response to pain by
behavioural techniques enhancing the body’s
natural pain relief
such as meditation and
response.
deep breathing
exercises. 5 Reassessing pain ill
5 Reassess patient;s determine the
pain level within 1 hour effectiveness of prior
interventions and need for
further.
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Risk for infection as Throughout 8 hours of 1 Perform medical 1 Medical handwashing Throughout 8 hours of
Patient voiced “more evidenced by independent and handwashing technique reduces the number and independent and
while the access get proliferation of the dependent nursing before and after contact transfer of micro- dependent nursing
wet when I bathe” “Di epithelial cells in the interventions patient with the patient organisms thereby interventions patient
peepi bag nuh have any gallbladder secondary will remain free of preventing cross remained free of
string so mi just rest it to gallbladder cancer. infection as evidenced 2 Advise patient to contamination infection as evidenced
pon th bed” Patient voicing “more by absence of odour, clean labia majora, by absence of odour,
while the access get pain, redness or minor and the outer 2 Cleaning the area pain, redness or
Objective wet when I bathe.” “Di swelling at the catheter area of the catheter daily will reduce the swelling at the catheter
IVA instituted to right peepi bag nuh have any and IVA site. with soap and water the number of and IVA site.
dorsum. string so mi just rest it dry with a clean towel, microorganisms and
Urinary catheter pon th bed.” IVA daily. prevent cross
instituted on free instituted to right contamination
drainage with 300 cc or dorsum. 3 Advise patient to
amber coloured urine. Urinary catheter keep the urine bag 3 This prevent the urine
Gallbladder cancer instituted on free lower than the level of from back flowing into
drainage with 300 cc or the bladder the bladder, thereby
amber coloured urine. reducing contamination
4 Empty the contents of
the drainage bag at 4 Emptying the urine
least once or whenever will prevent the bag
it is three quarter full from becoming too
heavy which may pull
5 Educate patient on on the catheter and
the importance pf cause dislodgment
keeping the area, where
the catheter and IVA 5 A moist environment
are instituted, dry. encourages the growth
of microorganism that
may cause
contamination
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Deficient knowledge Within 1 hour of 1 Provide a calm, 1 A comfortable Goal met. Within 1
Patient verbalized, related to limited nursing and quiet and comfortable environment will hour of nursing and
“Mi nuh know what access to information collaborative care environment to facilitate the patient’s collaborative care
name so.” as evidenced by patient will facilitate learning. openness to learn. patient demonstrated
Patient asked “A dat patient verbalizing demonstrate improved knowledge
a the antibiotic?” “Mi nuh know what improved knowledge 2 Establish a 2 A therapeutic about Dolutegravir as
name so.” “A dat a about Dolutegravir as therapeutic nurse- relationship will evidenced by patient
Objective the antibiotic?” evidenced by patient patient relationship foster trust and help stating the use and 1
Patient shrugs Patient shrugs stating the use and 1 patient to be possible side effect of
shoulder and shoulder and possible side effect of receptive to the the drug.
scratches head when scratches head when the drug information given by
asked about the asked about the nurse
medication medication.
Patient learns best 3 Educate the patient 3 Dolutegravir is a
from watching videos on the usage and HIV integrase
mechanism of action inhibitor that blocks
Medication- for Dolutegravir the catalytic activity
Dolutegravir 50 mg using a youtube of HIV integrase,
PO video. which is required for
viral replication.
Thereby decreasing
the amount of HIV in
the blood and
increasing the
number of immune
cells.

4 Educate the patient 4 Patient will know

on the side effects of when to notify the
Dolutegravir nurse once they are
 knowledgeable about
what to look out for.
Some side effects
include skin rashes,
insomnia, liver
problem and
headaches

5 Provide patient 5 Giving the patient

with the opportunity an opportunity to
to ask questions voice questions will
allow the nurse to do
the necessary
corrections and
elaborate on what is
unclear to the patient.

Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Risk for infection as Throughout 8 hours 1 Perform medical 1 Medical Goal met.
Patient voiced “the evidenced by patient of independent and handwashing before handwashing reduces Throughout 8 hours
cut itch mi voiced “The cut itch dependent nursing and after contact with the number and of independent and
sometimes and mi mi sometimes and mi intervention the patient transfer of dependent nursing
feel a little burning feel a little burning patient will remain microorganism, intervention the
there” there.” Dressing free of infection as thereby preventing patient remained free
noted to right and left evidenced by cross contamination. of infection as
Objective crural region. Pink maintenance of pink evidenced by
Dressing noted to granulating tissue granulating tissue, 2 Perform aseptic 2 Aseptic wound care maintenance of pink
right and left crural that is uncovered at with absence of wound care as promotes healing and granulating tissue,
region right and left femoral odour, pain, redness, ordered. decreases the with absence of
Pink granulating region. swelling and purulent potential for bacterial odour, pain, redness,
tissue that is drainage. formation. swelling and purulent
uncovered at right drainage.
and left femoral 3Apply tetracycline 3 Tetracycline
region ointment to the ointment will inhibit
wound observing bacterial protein
Medication- aseptic technique synthesis by binding
Augmentin 1 g PO to 30s and 50S
and Tetracycline ribosomal units.
ointment 4 Administer
prescribed 4 Augmentin will
Augmentin 1 g PO. bind to the protein in
the bacterial cell wall
and inhibit the
synthesis and growth
of bacteria.
5 Advocate for a diet
that is high in protein 5 Protein is an
for the patient essential
 macronutrient that is
responsible for repair
and maintenance or
bodily cells.
6 Educate patient on
the importance of 6 A moist
keeping the wounds environment
dry and preventing it encourages the
from touching growth of
anything in the microorganism that
environment. may cause
contamination.
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Decreased activity Within 8 hours of 1 Discuss energy 1 Awareness and Goal met. Within 8 hours
Patient verbalized tolerance related to independent and conservation goals and participation in goal of independent and
‘anytime mi walk mi get imbalance between dependent nursing behaviors with the setting will facilitate dependent nursing
short a breath” “anytime oxygen supply and interventions, the patient patient. cooperation and enhance interventions, the patient
the physiotherapist come demand as evidence by will demonstrate at least motivation on the patient. demonstrated at least one
and do har thing mi just patient’s complain of one energy conservation 2 Explore the different energy conservation
tired and weak out and a tiredness, shortness of behavior such as utilizing assistive devices 2 Using assistive device behavior. They were
just likkle walking mi a breath upon walking. R- assistive device, request accessible to and safe for will help the patient to using a wheelchair and
do.” 29 bpm and SpO2 95% assistance with ADL the patient such as conserve her energy, request assistance with
on 3L of O2. when necessary and wheelchairs or canes. since her weight will be putting on clothes.
Objective taking breaks/rest periods Allow the patient to on the device while
Use of accessory muscles. between activities. choose one. moving around.
Deep breathing.
R-29 bpm 3 Advocate for patient to 3 Physiotherapists are
Spo2- 95% on 3L of O2 be taught how to properly experts in this area and
via nasal cannula use selected device. they can teach the patient
how to use the device
4 Advice patient to with the lease amount if
request assistance with energy required.
ADL
4 Even though
5 Explain the benefits of independence is
taking breaks/rest periods important, requesting
between activities assistance with self- care
when necessary will help
the patient to better
tolerate the activities.

5 Rest allows the patient

to build up energy reserve
and replenish energy lost
in previous activities.
Explaining this to the
patient will help her
understand and make an
informed decision.
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Risk for adult fall as Within 8 hours of 1 Maintain bed in the 1 The lowest position Goal met. Within 8
Patient verbalized, evidenced by patient nursing and lowest position. will facilitate easier hours of nursing and
“mi cannot stand up verbalized, “mi collaborative care the transfers from bed to collaborative care,
too long.” “Mi just cannot stand up too patient will not wheelchair and vice the patient did not
do the surgery 4 days long.” “Mi just do the sustain any falls as versa, thus sustain any falls as
ago and mi cannot surgery 4 days ago evidenced by no falls preventing falls. evidenced by no falls
balance enough to and mi cannot reported and no reported and no cuts,
even use crutches” balance enough to physical injuries, 2Raise bed railsx2 2 Bed rails are scrapes or bruises,
even use crutches.” such as cuts, scrapes when patient is protective observed.
Objective Right BKA noted. or bruises, observed occupying bed. components that
Right BKA noted Patient uses helps to keep the
Patient uses wheelchair to patient from falling
wheelchair to mobilize. Patient off the sides of the
mobilize. unable to stand and bed.
Patient unable to maintain balance and
stand and maintain posture. 3 Place a ‘fall 3 To alert nursing
balance and posture. precaution’ sign staff of the patient’s
above the patient’s increased risk of
bedside falls.

4 Place all personal 4 Putting personal

items within reach of items in close
the patient proximity will
prevent the patient
from stretching or
getting out of bed, to
get what they want,
thus lowering the risk
5 Ensure floor and for fall.
walk way is free of
spills 5Spills are hazard for
falls. Cleaning spills
as soon as possible
and putting up the
wet floor sign thus
lowering the risk for
6 Ensure walk way is falls.
clutter free
6 Clutter free
environment provides
a clear path to get to
7 Assist patient with and from bed.
transfer from bed to
wheelchair 7 To minimize the
potential of patient
sustaining injury.
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Disturbed sleep Within 8 hours of 1 Change the nasal 1 Facemask goes Goal met. Within 8
Patient verbalized pattern related to nursing and cannula to a over the nose hours of nursing and
“Mi want sleep and environmental collaborative care the facemask to continue therefore it will collaborative care,
cannot sleep cause disturbances and patient will identify 5 supplemental O2 provide more comfort the patient identified
the thing in my nose discomfort from measures to therapy. that will facilitate a 5 measures to
uncomfortable and treatment as implement to better sleep pattern implement to
dem wake mi up 4;30 evidenced by patient improve sleep pattern 2 Show the patient for the patient. improve sleep
in the morning to verbalizing “Mi want such as using an O2 what a sleep mask is pattern. They were
bathe then mi cannot sleep and cannot facemask, using a and inform him of the 2 Sleep masks can using an O2
go back to sleep. Plus sleep cause the thing sleep mask, using benefits. help to obstruct the facemask, using a
the light and the TV in my nose earplugs, creating a bright lights at the sleep mask, using
is always on.” uncomfortable and schedule with the hospital. Showing earplugs, creating a
dem wake mi up 4;30 night shift staff and and explaining the schedule with the
Objective in the morning to using white noises. benefit will enable night shift staff and
Patient tossing in bathe then mi cannot the patient to make using white noises.
bed. Hissing of teeth go back to sleep. Plus an informed decision
and sighing. Under the light and the TV about whether to get
eyes appears puffy. is always on.” Patient a sleep mask or not.
Patient on tossing in bed.
supplemental O2 via Hissing of teeth and 3 Explain the use of 3 Earplugs/muffs can
nasal cannula. sighing. Under eyes earplugs or muffs in help to decrease the
appears puffy. the hospital sounds in the hospital
environment. environment that
might prevent the
4 Inform the patient patient from sleeping.
that discussing a Explaining the use
schedule of care with will help patient to
the night shift nurse make an informed
is an option he has decision.
and discuss this with
the staff during hand 4 Creating a schedule
over/ report. helps the patient to
better plan his sleep
and could result in
longer undisturbed
sleep due to grouping
of care.

5 Introduce the 5 White noises refers

patient to white to sounds that mask
noises other sounds that
might occur naturally
in the environment
and is known to aid
sleep. Patient could
use his phone to play
white noise for a
period.

6 Allow patient to 6 To determine if the

verbalize the 5 patient understood
measures explained. and was able to recall
the measures. This is
necessary for
implementation by
the patient to take
place.
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Impaired memory With 8 hours of nursing 1 Provide a calm, quiet 1 A comfortable With 8 hours of nursing
Patient verbalized “Mi related to and collaborative care and confortable environment will and collaborative care
cannot remember the 3 neurochemical patient will environment. facilitate openness to patient demonstrated
things that you said” imbalances secondary demonstrate improved learning. improved memory as
“mi born December 14, to schizophrenia as memory as evidenced evidenced by patient
1973” evidenced by patient by verbalizing correct 2 Approach patient in a 2 This will help the verbalizing “Mi born
verbalizing, “mi cannot DOB and 3 items calm manner and give patient to feel relaxed August 26, 1985 and
Objective remember the 3 things given. him time to respond and allow him to the three things weh
Docket verified DOB that you said.” “mi concentrate. you ask mi to
as August 26, 1985. born December 14, remember are apple,
Patient looked puzzled 1973.” Docket verified 3 Administer Haldol 5 3 Haldol works by pencil and shoes.”
and uncertain, shrugs DOB as August 26, mg PO balancing out the
shoulders. 1985. Patient looked neurochemicals and
Poor remote and puzzled, uncertain and enable the patient to
immediate memory shrugs shoulders. think clearly.
4 Write the pateint’s
Medication- Haldol 5 DOB and 3 items on a 4 Using visual imagery
mg PO piece and paper and facilitate memory and
give it to him. will help the patient to
correctly recall DOB
and the 3 items.

5 Allow patient to 5 Repetition helps to

repeat information on reinforce memory
the paper for stability
undisturbed period.
6 The patient can jot
6 Advise the patient to down important details
keep a daily journal in the daily journal that
will facilitate improved
memory.
Assessment
Subjective
Patient verbalized, “I like
to stay to myself because
I don’t like talking, I
rather to meditate.”
Objective
Patient sitting alone and
staring in space.
Avoids eye contact
Patient does not expound
on topics, only give direct
answers.
Flat affect and restrictive
speech
Diagnosis
Impaired social
interaction related to
inadequate social skills as
evidenced by patient
verbalizing, “I like to stay
to myself because I don’t
like talking, I rather to
meditate.”
Patient seen sitting alone
and staring in space,
avoids eye contact.
Patient does not expound
on topics, only give direct
answers. Flat affect and
restrictive speech noted
Outcome
Throughout 8 hours of
nursing and collaborative
care the patient will
demonstrate improved
social interaction as
evidenced by patient
participating in group
activities with co-patients
and talking to nurse.
Interventions
1 Establish a therapeutic
nurse- client relationship.
2 Establish short and
simple conversation with
the patient every 30
minutes.
3 Allow visitation of the
patient’s loved ones as
much as possible
4 Provide the patient with
social engagement
activities such as playing
dominoes or cards.
5 Provide the patient with
positive verbal and non-
verbal feedback for
appropriate behavior and
praise for making an
effort.
6 Allow the patient to
verbalize his thoughts and
feelings in a calm
environment
Rationale Evaluation
1 A therapeutic relationship Throughout 8 hours of
will foster trust and allows nursing and collaborative
for effective communication care the patient
.
demonstrated improved
2 This can help prevent
isolation provide a sense of
social interaction as
connection and support evidenced by patient
which can encourage playing dominoes with
communication. co-patients and talking to
nurse to the nurse about
3 This will encourage social the latest broadcasting
contact and can be news.
therapeutic because patient
can talk to persons outside of
the hospital.
4 Social engagement
activities can help the patient
to initiate social interactive
with co-patients. It can also
increase feelings of
belonging.
5 This allow the patient to
understand social cues and
appropriate behavior. Also,
learn to remember what is
expected of him. Praising
can also motivate to
continue improving.
6 This will build confidence
and self-esteem which will
allow the patient to articulate
his thoughts and feelings
better, as well as improve his
ability to interact with
others.
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Ineffective coping Within 8 hours of 1 Establish rapport 1 To provide a Within 8 hours of
Patient verbalized “I related to separation independent and with the patient. comfortable and calm independent and
am tired of being in from family as dependent nursing environment for the dependent nursing
here, mi want go home evidenced by patient interventions the 2 Use therapeutic patient. interventions, the
to mi wife” verbalizing “I am tired patient will display communication such as patient displayed
2 This will foster trust
of being in here, mi improved coping as active listening and and facilitate openness
improved coping as
Objective want go home to mi evidenced by patient touching when talking from the patient. evidenced by patient
Staring blankly with wife.” Patient stares accepting diet to patient. accepting diet
teary eyes. blankly with teary eyes. throughout the shift, 3 Showing understanding throughout the shift and
Patient has refused Patient has refused seen communicating 3 Advise the patient to and empathy will create seen communicating
food for 3 days now. food for 3 days now. with co-patients and/or verbalize feelings and an environment of with co-patients.
Isolates self and Isolate self and remains nurses. concerns without acceptance where patient
covered head under bed covered under judegement. can voice honest
sheet. bedsheets thoughts.
4 Provide the patient
4 Diversional therapy
with diversional
will redirect the patient’s
activities such as focus from negative
listening to music or thoughts.
watching television.
5 Positive coping
5 Teach the patient strategies help to regulate
positive copng emotions and reduce
strategies such as feelings of distress and
listening breathing anxiety.
exercises, meditation.
6 Group therapy can help
patient to identify
6 Engage patient in stressors and help to
group therapy. improve patient’s
confidence in the ability
to cope with
stressors/challenges.
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Impaired skin Throughout 8 hours 1 Perform medical 1 Medical handwashing Throughout 8 hours
Patient voiced “ I met integrity elated to of independent and handwashing prior reduces the number and of independent and
in an accident and the mechanical trauma to dependent nursing and after patient transfer of dependent nursing
bone did come crural region interventions patient contact microorganism, thereby interventions patient
preventing cross
through the skin so secondary to MVA as will remain free of remained free of
contamination.
they did a surgery evidenced by patient infection and wound infection and wound
and put in back the voicing, “I met in an healing will be 2 Perform aspetic 2 Aseptic wound care healing be promoted
bone then sew it up” accident and the bone promoted as wound care as promotes healing and as evidenced by
did come through the evidenced by ordered reduces the potential of maintenance of
Objective skin so they did a maintenance of bacterial formation. healthy suture line
Windowed cast note surgery and put it healthy suture line with absence of
to distal portion of back in then sew it with absence of 3 Administer 3 Bactrim blocks two odour, pain, redness,
lower left extremity. up. Windowed cast to odour, pain, redness, prescribed Bactrim 2 consecutive steps in the swelling and purulent
Suture line noted to left crural region with swelling and purulent tabs PO biosynthesis of nucleic drainage.
crural region covered covered suture line. drainage. acids and proteins
essential for bacterial
by dry and clean
formation
dressing.
4 Advocate for a diet 4 Protein is an essential
Medication- Bactrim high in protein for the macronutrient
2 tabs PO patient responsible for repair
and maintenance of
bodily cells.

5 Educate patient on 5 A moist environment

the importance of encourages the growth
keeping the wound of microorganism that
may cause
dry.
contamination of the
wound.
Assessment Diagnosis Outcome Interventions Rationale Evaluation

Subjective Ineffective breathing Within 8 hours of 1 Advocate for the 1 Oxygen therapy Within 8 hours of
Patient voiced “I can pattern related to nursing and patient to get delivers O2 directly nursing and
not breath properly, it decreased lung collaborative prescribed 3L of to the lungs thereby collaborative
hard.” capacity due to interventions, the supplemental oxygen increasing its level at interventions, the
accumulation of fluid patient will via nasal cannula. alveolar space thus patient experienced
Objective in pleural space as experience an promoting an improvement in
Crackles at the base evidenced by patient improvement in oxygenation breathing pattern as
of lungs bilaterally. complaining of breathing pattern as evidenced by the
Mild respiratory breathing difficulty, evidenced by the 2 Maintain bed in a 2 Elevation of bed patient verbalizing “I
distress observed at chest xray showing patient verbalizing an semi-fowler to high promotes maximum am breathing better”,
rest. pleural effusion, improvement “I am fowler’s position lung expansion R- 23 bpm, SpO2
R-29 bpm SpO2 90% without able to breathe thereby facilitating above 96% on 2L of
SpO2 90 without O2, R- 29 bpm, better”, respiration optimum O2
supplemental O2 crackles heard at the rate no higher than 24 oxygenation. Also
Chest xray confirms base of the lungs bpm, SpO2 above forces fluid in the
pleural effusion bilaterally. 95% on 3L or less of pleural space down to
O2 the base of the lungs.

3 Loosen all tight 3 This will allow

clothing optimum blood
circulation in the
body which improves
oxygenation when it
reaches the alveolar
space.

4 Educate and 4 This exercise is a

instruct patient to lung expansion
perform deep technique commonly
breathing exercises used in patient with
every 1 hour gaseous exchange
problem as it allows
the respiratory sytem
to fully exchange
incoming O2 with
outgoing CO2
5 Provide an
incentive spirometry 5 This helps to
devise and instruct improve lung
the patient to use it function by keeping
every hour. the lung active. It
encourage deep
breathing, lung
expansion and mucus
clearance, which
optimize ventilation.
6 Decrease the O2
therapy by 1L after 3 6 To see if patient is
hours and reassess able to use less
breathing pattern. supplemental oxygen
while maintain
adequate ventilation