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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: ͞Masakit ang Acute pain After 8 hours of nursing Independent: After 8 hours of nursing
pagihi ko͟ as related to interventions, the ͻ Provides ͻ Assess pain, interventions, the
verbalized by the urinary tract patient͛s pain information to noting location, Patient reports that the pain
patient. infection as manifested by : will be aid in intensity (scale of is relieved.
͞Masakit ang pagihi ko͟ as relieved or determining 0 ʹ 10), duration.
verbalized by the patient. control in a manageable way. choice or
effectiveness of ͻ Encourage
Interventions. increased fluid
Objective: intake.
c ëacial grimace. ͻ Increased
c Restlessness. hydration ͻ Investigate report of
c Pain scale of 7/10 flushes bacteria bladder fullness.
c Limited ROM and toxins.
c V/S taken as follows: ͻ Observe for
ͻ Urinary changes in
T: 37.3 retention may mental status,
P: 82 develop, behavior or level
R: 19 causing tissue of consciousness.
BP: 140/90 distention (
bladder or ͻ Provide comfort
kidney), and measure like
potentiates risk for further back rub, helping
infection. patient assume
position of
ͻ Accumulation of comfort. Suggest
uremic waste use of relaxation
and electrolyte technique and
imbalances deep breathing
may be toxic to exercises.

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the CNS.

ͻ Promotes
relaxation,
refocuses
attention, and
may enhance
coping abilities

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: > Imbalanced Nutrition less After 1 day of > Determine client͛s > Provides baseline data After 1 day of
than body requirements nursing nutritional history about the client nursing
͞Hindi ako makakain ng related to pain. interventions, the interventions, the
maayos kasi hirap ako client will be able > Educate the client > Assess the usual client is able
makalunok͟ as verbalized by To demonstrate changes in regarding the food that she eat To demonstrate changes in
the patient. her diet as importance of eating her diet as
manifested healthy foods manifested
Objective: by proper by proper
food selection. > Educate the client > ëor the client to be food selection.
c ëacial grimace regarding the vitamins aware of the needed
c Body weakness and minerals nutrients by her body
to nourish herself

> Plan with the client her > Involving the client to
desired meal her plan of care gives
the client the feeling
of independence. It
also personalizes the
plan of care since the
client does make the
choices in some
aspects of the plan.

> Instruct the client to

follow the prescribed
number of servings of
the meals included in her
meal plan.

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective : Impaired physical mobility > After 6 days of >Assist patient to > To improve muscle strength and joint > After 6 days of
related to pain as manifested nursing intervention, do active ROM mobility. nursing intervention,
͞Medyo di pa ako by ͞Medyo di pa ako the patient will be able to She is able demonstrates and
makakilos ng gaya makakilos ng gaya demonstrates and >Establish patient > Bed rest decreases body metabolism perform activities of
dati dahil may sumasakit dati dahil may sumasakit perform activities of to have adequate thus reduces muscle tension. daily living with
sakin͟ as verbalized by the sakin͟ as verbalized by the daily living with bed rest. minimal assistance
patient. patient. minimal assistance
>Accepts client > To achieve pain management and
Objective: description of goals.
c Pain scale of 6/10 pain.
c BP=130/90
c ëacial grimace
c Limited ROM
c Guarding behavior

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ASSESSMENT DIAGNOSIS PLANNING Intervention Rationale EVALUATION

Subjective: Risk for Loneliness related to After 2 days of nursing >Assess sleep >Indicators of distress related After 2 days of nursing
Social isolation intervention the client will disturbances, ability to to feeling of loneliness and low intervention the client can
͞ëeeling ko ako nalang engage in social activities concentrate. self esteem. engage in social activities
magisa kasi hindi ako and reports involvement in and reports involvement in
inaalagan ng mga anak ko social interaction. >Identify individual >To provide opportunities for social interaction.
dahil may sakit ako͟ as strength, areas of involvement with others.
verbalize by the patient. interest.

Objective: >Let client know that >It is up to the individual to

c ëacial loneliness can be build self esteem and learn to
grimace overcome. feel good about self.

> Support expression of >Provides opportunities for

negative perceptions of client to clarify realty of
others and whether situation, recognize own denial.
client agrees,

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ASSESSMENT
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DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: > Disturbed sleeping pattern > After 3 days of nursing >Provide quiet environment >provides conducive > After 3 days of nursing
related to pain as manifested intervention the client will environment to relax. intervention the client is able
͞Hindi ako makatulog kasi by ͞Hindi ako makatulog kasi be able to reestablish and to reestablish and maintain
minsan ang sakit ng katawan minsan ang sakit ng katawan maintain normal sleep >Provide comfort measure >soothes and relaxes the his normal sleep pattern
ko͟ as verbalized by the ko͟ as verbalized by the pattern ( backrub) client.
patient patient.
>Recommend limited intake > Caffeine inhibits sleep.
of caffeine and chocolates
Objective: prior to seep.

>Explore other sleep aids >To promote wellness

>ërequent yawning in
daytime >Refer to sleep specialist for >ëor advice from a specialist.
treatment as indicated.
>Dark circles around the
eyes

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