ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Impaired Fibromyalgi Short-term Goal: - Conduct regular - Effective pain -After the
SUBJECTIVE Comfort a etiology pain assessments management nursing
DATA: related to ↓ Within the using a pain scale reduces intervention
muscle spasms Central next 48 to determine the discomfort , the short-
- Patient secondary to Nervous hours, the patient's pain and may help term goal
reports fibromyalgia as System patient will level. with sleep and long-
frequent evidenced by Sensitization report a - Administer and mood term term
muscle disturbed ↓ reduction in prescribed pain improvement. was met
medications and
spasms sleeping Muscle muscle
interventions
and pain patterns and Spasms and spasms and promptly based
due to irritability. Tension pain, on the assessed
fibromyal ↓ improved pain level.
gia. Disturbed sleep
- Patient Sleep patterns, - Educate the - Improving
patient on sleep sleep patterns
complains Patterns and a
hygiene practices,
of ↓ reduction in can
such as
difficulty Altered irritability. maintaining a contribute to
sleeping Neurotransm regular sleep better
and itter Activity Long-term Goal: schedule, comfort and
creating a overall well-
feeling ↓ By the time
comfortable sleep being.
irritable Increased of environment, and
due to Irritability discharge, avoiding
discomfor and Stress the patient stimulants close
t. ↓ will have an to bedtime.
Decreased enhanced
OBJECTIVE Physical level of
- Teach the patient - Reducing
DATA: Activity comfort,
relaxation stress and
- Restlessn ↓ improved
techniques, irritability
ess Impaired sleep
including deep can
- Irritability Comfort quality, and
breathing positively
- Pain: 8/10 better mood
Vital signs as managemen exercises and impact the
taken: t in the mindfulness, to patient's
BP: 120/70 context of help manage comfort and
mmHg fibromyalgi stress and overall
PR: 80 bpm a. irritability. mood.
RR: 20
breaths/min - Assist the - Proper
O2Sat: 97% patient in positioning
finding and mobility
comfortable can help
positions, use relieve
pillows or muscle
cushions as spasms and
needed, and reduce
encourage discomfort.
gentle stretching
exercises to
alleviate muscle
spasms.

- Educate the - Patient

patient about understandin
their g and
fibromyalgia adherence to
medications, treatment
their purpose, can lead to
and potential better long-
side effects. term
Encourage management
adherence to of
prescribed fibromyalgia
treatments. symptoms.

- Provide - Addressing
 emotional emotional
support and distress and
encourage the connecting
patient to with others
consider joining experiencing
fibromyalgia similar
support groups challenges
for additional can
peer support. positively
impact long-
term comfort
and coping.
JOSEPH P. NATIVIDAD WEEK 9

BSN3A

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Impaired Insufficient - Provide the - Review the - This brings After a
SUBJECTIVE comfort related privacy patient with knowledge base these to nursing
DATA: to insufficient perception an and note coping client’s intervention
privacy ↓ environmen skills that have awareness , the patient
“Di po ako physiologica t that been used and promotes met the goal
mapakali” as l changes respects previously to use in the
verbalized by the ↓ their need change current
patient stress for privacy, behavior/promot situation.
response ensuring e well- being.
OBJECTIVE activation their
DATA: ↓ comfort and - Acknowledge the
- Restlessn physiologica dignity. client’s strengths
 ess l changes in the present
- irritability ↓ situation and
Vital signs as disrupted build on these in
taken: sleep planning for the
BP: 110/80 patterns future.
mmHg ↓
PR: 80 bpm loss of - Provide a quiet
RR: 20 control environment,
breaths/min ↓ calm activities.
O2Sat: 97% reduced - This promotes
- Provide for
dignity and a client’s
periodic changes
self-esteem sense of self-
in the personal
↓ control and
surroundings
impaired environmenta
when the client is
comfort l comfort.
confined. Use the
individual’s input
to create changes
(e.g., seasonal
bulletin boards,
color changes,
furniture
rearranging
furniture, or
pictures).

-
ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE Anxiety related Physical Short-term Goal: After the
DATA: to physical Abuse - Ensure the - A safe nursing
- Patient abuse ↓ - Within the patient is in a environment intervention
reports Immediate next 24 secure and is essential for , the short-
feeling Psychologic hours, the private reducing term goal
anxious, al Response patient will environment immediate was met the
fearful, or ↓ report a away from anxiety and goal and the
on edge. Hyperarousa reduction in potential promoting a long term
l and anxiety triggers or sense of goal was
OBJECTIVE Increased symptoms reminders of the security.. partially
DATA: Alertness and abuse. met the goal
- Restlessn ↓ demonstrate
ess, Flashbacks the use of - Engage in active - Effective
- Sweating and Intrusive effective listening and communicati
- Tremblin Memories coping provide on helps
g ↓ strategies to empathetic build trust
- Difficulty Hypervigilan manage responses to the and provides
concentrat ce anxiety. patient's emotional
ing ↓ - concerns and support,
 Negative Long-term Goal: feelings of which can
Vital signs as Cognitive - By the time anxiety. alleviate
taken: Patterns of anxiety.
BP: 130/90 ↓ discharge,
mmHg Avoidance the patient - Educate the - Relaxation
PR: 101 bpm Behaviors will have patient on techniques
RR: 23 ↓ developed a relaxation promote
breaths/min Increased comprehens techniques, such physiologica
O2Sat: 99% Physiologica ive safety as deep l calmness
l Arousal plan and breathing and reduce
↓ demonstrate exercises, anxiety
Impaired d improved guided imagery, symptoms.
Coping coping and progressive
Mechanisms mechanisms muscle
↓ to manage relaxation.
Anxiety anxiety
related to - Collaborate with - A safety plan
their history the patient to empowers
of physical develop a safety the patient to
abuse. plan, including take control
identifying safe of their
places, safety,
emergency reducing
contacts, and anxiety
strategies for associated
self-protection. with ongoing
safety
concerns.
- Introduce - Cognitive-
cognitive- behavioral
behavioral techniques
strategies, such can help the
as identifying patient gain
and challenging control over
 negative thought their anxious
patterns and thoughts and
developing responses.
healthy coping
mechanisms.
- Connect the - These
patient with resources
local resources, provide
such as ongoing
counseling support and
services, support therapeutic
groups, and interventions
advocacy to address
organizations anxiety
for survivors of related to the
abuse. history of
physical
abuse.
ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
- -
SUBJECTIVE
DATA:

OBJECTIVE
DATA:

Vital signs as
taken:
BP: 110/80
mmHg
PR: 80 bpm
RR: 20
breaths/min
O2Sat: 97%
ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE Situational Physical Short-term Goal: - Establish a - A trusting -After the
DATA: Low Self- Neglect trusting and relationship nursing
Esteem related ↓ - Within the non-judgmental encourages intervention
rapport with the
- Patient to physical Lack of 2 days, the open , the short-
patient to create
may neglect Nurturing patient will a safe space for communicati term goal
verbalize and demonstrate expression. on and and long-
feelings Affection improved promotes a term term
of neglect ↓ self-esteem sense of was met
or lack of Absence of through the safety for the
care. Positive use of patient.
Role Models positive
- Encourage the
OBJECTIVE ↓ self-talk patient to - Allowing the
DATA: Negative and express their patient to
- Poor Self- engagement feelings, express
personal Perception in self-care thoughts, and themselves
hygiene ↓ activities. concerns related fosters self-
- Withdraw Low Self- to their self- awareness
esteem and past
n Esteem Long-term Goal: and can lead
experiences of
behavior Patterns - By the time neglect. to insight
Emerge of and healing.
Vital signs as ↓ discharge,
taken: Negative the patient - Encourage the - Cognitive
BP: 110/80 Cognitive will have use of positive restructuring
mmHg developed affirmations and helps
Patterns
reframing challenge
PR: 91 bpm ↓ healthy negative
RR:18breaths/min Impact on self-esteem and change
thoughts into
O2Sat: 98% Interpersonal and be more positive negative
Relationship equipped and realistic thought
s with coping perspectives. patterns,
↓ strategies to promoting
Avoidance address improved
of feelings of self-esteem.
Opportunitie low self- - Educate and
worth assist the patient - Actively
 s related to in engaging in participating
↓ past self-care in self-care
Self- neglect. activities, such promotes a
as personal
Fulfilling sense of self-
grooming,
Prophecy hygiene worth and
↓ routines, and reinforces
Situational activities that positive self-
Low Self- promote a sense image.
Esteem of well-being.
- Continuously - Ongoing
offer emotional emotional
support,
support helps
empathy, and
validation of the build the
patient's patient's
experiences and confidence
feelings. and sense of
self-worth
over time.
- Connect the
- Professional
patient with
mental health therapy can
professionals, offer
such as structured
therapists or interventions
counselors, who and
can provide strategies for
specialized
improving
support for
addressing self- self-esteem.
esteem and the
impact of past
neglect.
ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE Social Isolation Psychologic Short-term - Build a trusting - Trust is -After the
DATA: related to al Abuse Goal: and non- essential for nursing
- Patient Psychological ↓ judgmental the patient to intervention
therapeutic
may Abuse Erosion of - Within the feel , the short-
relationship with
express Self-Esteem 24 hours, the patient to comfortable term goal
fear or ↓ the patient create a safe discussing and long-
apprehens Creation of will space for their term term
ion about Dependency demonstrate expressing experiences was met
interactin ↓ improved feelings of and working
g with Isolation comfort and isolation. towards
others due Tactics confidence overcoming
to Begin in social social
 previous ↓ situations isolation.
psycholog Diminished and initiate
ical Trust in at least one - Gently - Encouraging
encourage the
abuse. Others social social
patient to
↓ interaction participate in engagement
Reduced per day. low-stress social helps the
OBJECTIVE Social Long-term Goal: activities, such patient
DATA: Engagement - By the time as group therapy gradually
- discomfor ↓ of sessions, art reintegrate
t in social Avoidance discharge, classes, or into social
support groups.
settings. of the patient settings and
Relationship will have build
Vital signs as s established confidence.
taken: ↓ a supportive - Introduce
BP: 100/70mmHg Loss of social cognitive- - Cognitive-
PR: 75 bpm Social network behavioral behavioral
RR: 20 Support and strategies to techniques
challenge and empower the
breaths/min ↓ demonstrate
reframe negative
O2Sat: 97% Heightened d effective patient to
thought patterns
Vulnerabilit communicat or beliefs about develop
y ion and social more
↓ relationship interactions. positive and
Social -building realistic
Isolation skills. perceptions
of social
interactions.

- Offer - Understandi
psychoeducation ng what
on healthy constitutes a
relationship healthy
dynamics, relationship
boundaries, and
lays the
effective
communication foundation
 skills. for building
meaningful
connections.

- Group
- Organize or
encourage activities
participation in create a
group activities supportive
that provide environment
opportunities for for the
social patient to
interaction and
practice
mutual support.
social skills
and connect
with others.

- Connect the - Engaging

patient with with
local community community
resources, such
resources
as social clubs,
volunteer offers
organizations, or opportunities
hobby groups, to for social
expand their interaction
social network. and
relationship-
building.