NCP 1: Acute pain related to inflammatory process as evidenced by redness and swelling of joints.

CUES/ NURSING BACKGROUND GOALS AND NURSING INTERVENTIONS AND EVALUATION

ASSESSMENT DIAGNOSIS KNOWLEDGE OBJECTIVES RATIONALE
Subjective: Acute pain related to Acute Pain is defined NOC: NIC:
Client verbalized inflammatory process as as the unpleasant  Pain Level Pain Management
“ Sobrang sakit ng mga evidenced by redness sensory and
kamay at paa ko, and swelling of joints. emotional experience GOAL: After the nursing
umiiyak pa ako dahil sa associated with actual After the nursing interventions, the client will
sakit.” or potential tissue interventions, the client be able to be relieved from
damage, or described will be able to be pain and discomfort.
Objective: in terms of such relieved from pain and
damage (NANDA, discomfort.
Facial grimace 15TH Ed, Page 633).
Pain level: 8/10 Patients with gout The client was able to:
often find it difficult OBJECTIVES: INTERVENTIONS:
to walk or stand when Within 8 hours of During the health care, the nurse will:
they are having flare- nursing interventions,
ups in their feet, the client will be able
knees, or ankles to:
because of severe and 1. Cooperate in all nursing
sudden pain and 1. Build rapport with the client. interventions. She
swelling. 1. Cooperate in all To elicit trust and for the client to give her successfully participated
nursing full participation during interventions. to alleviate her pain.
interventions.

2. Identify baseline 2.1. Assess pain, noting location, 2. Explain the severity of
data of her pain. characteristics, and severity (0 to 10 her pain by verbalizing
scale). Using a pain scale is useful in the location,
monitoring the effectiveness of medication characteristics, and rate
and the progression of healing. Changes in her pain. The pain level
 characteristics of pain may indicate decrease from 8/10 to
developing abscess or peritonitis, requiring 4/10
prompt medical evaluation and
intervention.
2.2. Assess the client’s vital signs. Monitor
the client’s vital signs for changes in
temperature or heart rate.

3. Maintain a
comfortable 3.1. Maintain chair rest when indicated. 3. Alleviate her pain and felt
position. Schedule activities providing frequent relaxed.
periods and uninterrupted night time
sleep. Systemic rest during acute attacks is
important throughout all phases of disease
to reduce fatigue and improve strength.
3.2. Encourage patient to maintain
upright and erect posture when sitting,
standing, or walking. Maximizes joint
function, and maintains mobility.

4. Understand ways 4. Execute different ways to

to alleviate her 4.1. Provide diversional activities and relieve her pain when
pain. relaxation techniques. Diversional experiencing it such as :
activities refocus attention, promote - Deep breathing exercise
relaxation, and may enhance coping and relaxation techniques
abilities. - Avoiding strenuous
4.2. Administer analgesics as prescribed. activities
Relief of pain facilitates cooperation with - Taking NSAIDs and as
other therapeutic interventions, such as prescribed by the Doctor.
early ambulation.
4.3. Educate the client about the side
effects of pain medications. If pain
 medications are prescribed such as opioids,
ensure that the client knows not to drive or
operate machinery while taking the drugs.
5. Prevent further
complications 5. Encourage adequate fluid intake. To 5. Prevent further
assist with excretion of uric acid and complications of stone
decrease likelihood of stone formation formation by having
adequate fluid intake.
NCP 1: Activity intolerance related to acute pain as evidenced by decreased activity/weakness

CUES/ NURSING BACKGROUND GOALS AND NURSING INTERVENTIONS AND EVALUATION

ASSESSMENT DIAGNOSIS KNOWLEDGE OBJECTIVES RATIONALE
Subjective: Activity intolerance Activity Intolerance NOC: NIC:
related to acute pain as is an insufficient Activity Intolerance Energy Management
Client verbalized evidenced by decreased physiological energy
“Ganun ata talaga pag activity/weakness to endure or complete GOAL: After the nursing
tumatanda lumalabas required or desired After the nursing interventions, the client will
yung mga sakit at daily activities. interventions, the client be able to independently
humihina.” (NANDA, 15TH Ed, will be able to complete activities of daily
Page 4). independently complete living.
Objective: activities of daily living.

-Slow movement The client was able to:

OBJECTIVES: INTERVENTIONS:
Within 8 hours of During the health care, the nurse will:
nursing interventions,
the client will be able
to:

1. Cooperate in all Build rapport with the client. 1.Cooperate in all nursing
nursing interventions.
To elicit trust and for the client to give her
interventions. full participation during interventions.

Conduct a comprehensive assessment of

the client’s medical history, current
health status, medications, symptoms,
and limitations in physical activity.
A thorough assessment helps identify the
 underlying cause of activity intolerance,
allowing for tailored interventions.
Monitoring vital signs, oxygen saturation,
and other relevant parameters helps track
progress and detect any changes.

Assist with ADLs while avoiding patient

dependency
Assisting the patient with ADLs allows
conservation of energy. Carefully balance
provision of assistance; facilitating
progressive endurance will ultimately
enhance.

Collaborate with the patient to create an

individualized activity plan that involves
gradually increasing activity levels and
incorporating rest periods.
Gradually increasing activity levels helps
the patient build strength and endurance
while avoiding overexertion. Scheduled rest
breaks prevent excessive fatigue.

Teach the patient energy conservation

techniques, such as pacing activities, 2. Understand techniques to
2. Understand taking breaks, and prioritizing tasks to alleviate her discomfort.
techniques to avoid excessive fatigue. Teaching patients
alleviate her how to manage their energy levels and plan
discomfort. their activities can help them achieve better
task completion without exacerbating
symptoms.
 Provide assistance with safe positioning
and mobility techniques to reduce strain
on muscles and joints. Proper positioning
and mobility techniques can help minimize
discomfort and reduce the risk of injury
during movements.

Educate the patient about signs and

3. Aware and to symptoms that warrant immediate 3. Aware and understand for
prevent further medical attention, such as severe chest potential complications.
complications. pain or sudden worsening of symptoms.
Empowering patients to recognize and
respond to warning signs helps prevent
complications and ensures timely medical
intervention when needed.
 Cues Nursing Diagnosis Background Goals and Objectives Nursing Intervention and Rationale Evaluation
Subjective: Fear/Anxiety related to Unexplained anxiety NOC : Anxiety NIC: Anxiety Reduction GOAL MET.
She verbalized that she change in health status or fear of discomfort Control
feels really old, and she accompanied by To achieve the nursing interventions, the Goal :
thinks that she became autonomic responses Goal : nurse will: After the nursing
a burden to her family. (non-specific sources or After the nursing intervention, the patient
She also verbalized that not known by the intervention, the patient reduced anxiety as evidenced
“mahirap pag individual); feelings of will reduce anxiety as by normal posture, facial
tumatanda na”. concern because of the evidenced by normal expressions, body language
anticipation of danger. posture, facial and activity levels.
This is a warning signal expressions, body
of a threat that will language and activity
Objective: come and allow levels.
- Patient was unhappy individuals to take Objectives: After 3 hours of
and aloof action to approve the Objectives: After 3 nursing interventions, the
actions. hours of nursing patient was able to:
interventions, the
Anxiety is probably patient will be able to:
present at some level in - Acquire knowledge
every individual’s life, - Be informed about the regarding her condition
but the degree and the procedures
- Explain all activities, procedures, and
frequency with which it
issues that involve the client; use
manifests differs
nonmedical terms and calm, slow speech.
broadly. Each
In one study, preoperative information
individual’s response to
reduced the anxiety of clients undergoing
anxiety is different.
surgery under regional anesthesia (Jiala et
Some people are able to -Identify, disclose and
al, 2010).
use the emotional edge demonstrate techniques
that anxiety provokes to for controlling anxiety
stimulate creativity or - Practice relaxation
- Teach signs and symptoms of escalating
problem-solving techniques
anxiety, and ways to interrupt its
abilities; others can
progression (e.g., relaxation techniques,
become immobilized to
deep- breathing exercises, physical
a pathological degree. exercises, brisk walks, jogging, meditation).
The feeling is generally - Have a calm So the client can start using relaxation
categorized into four environment techniques; gives the client confidence in
levels for treatment having control over his anxiety.
purposes: mild,
moderate, severe, - Move the client to a quiet area with
and panic. minimal stimuli such as a small room or
The nurse can seclusion area (dim lighting, few people, - Adopt the peaceful
encounter the anxious and so on.) environment
patient anywhere in the Anxious behavior escalates by external
hospital or community. - Appear relaxed, able stimuli. A smaller or secluded area
The presence of to rest or sleep enhances a sense of security as compared to
the nurse may lend supp appropriately a large area which can make the client feel
ort to the anxious lost and panicked.
patient and provide
some strategies for - Encourage the client’s participation in
traversing anxious - Have a support system relaxation exercises such as deep breathing,
moments or panic progressive muscle relaxation, guided - display self-care practices
attacks. imagery, meditation and so forth.
Relaxation exercises are effective
nonchemical ways to reduce anxiety.

- Use empathy to encourage the client to

interpret the anxiety symptoms as
normal.
The way a nurse interacts with a client
influences his/her quality of life. Providing - Cope up progressively with
- Show no more psychological and social support can the help of his/her support
feelings of stress and reduce the symptoms and problems system
depression associated with anxiety ( undergoing
couples therapy felt significantly more trust
and responded with more success to those
therapists Wagner & Bear, 2009). In
another study, patients A who provided
empathetic and compassionate responses
and suggestions (Benson et al, 2012).

- Encourage client to set increasingly

more difficult goals.
Develops confidence and movement toward - Display positive behaviors
improved functioning and independence.