ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTIONS

Subjective Data: Acute pain related to After 3-4 hours of Independent: After 3-4 hours of
“Masakit ang sugat tissue damage as nursing interventions, 1. Assess the For baseline data nursing interventions,
ko.” As verbalized by manifested by facial the pain scale of the patient’s pain the pain scale of the
the patient. grimace and pain patient will decrease including the patient decreased
scale of 6/10. from 6 to 2. location, from 6 to 2.
Objective Data: characteristics,
- facial grimace Rationale: onset/duration,
- crying Acute pain because frequency,
- guarded or the patient has wound quality,
protective caused by tissue severity and
behavior damage. And the pain aggravating
- pain scale of that the patient feels factors.
6/10 doesn’t exceeds for 2. Assess for To help determine
- reduced more than 6months. referred pain. possibility of
interaction underlying condition
with people or organ dysfunction
and requiring treatment.
environment
- presence of 3. Monitor VS For baseline data
wound with
pus 4. Provide To provide
comfort nonpharmacological
measures (e.g pain management
back rub,
change of
position)
5. Encourage To divert the patient’s
diversional mind in interaction of
activities (e.g pain
TV/radio)

Dependent:
1. Administer To help the patient
analgesics as lessen the pain
prescribed by
the physician.
 ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS

Subjective Data: Activity intolerance Shot-term Goal: Independent: Short-term Goal:

“Nanghihina ako.” related to imbalance After 4 hours of 1. Assess degree To identify proper After 4 hours of
As verbalized by the between oxygen nursing interventions, of mobility. nursing intervention nursing interventions,
patient. supply and demand as the patient will be the patient was able to
evidenced by able to perform 2. Encourage To reduce fatigue and perform activities
Objective Data: decreased activities without patient to rest conserve energy without experiencing
- pallor hemoglobin- 71g/l. experiencing fatigue, in between fatigue, dizziness or
appearance dizziness or activities. weakness.
- inability to Rationale: weakness.
move Activity intolerance 3. Assist with To protect patient Long-term Goal:
especially because the patient Long-term Goal: activities. from injury After 1 week of
when she sits doesn’t have enough After 1 week of nursing interventions,
or stand up, energy to perform her nursing interventions, 4. Monitor For baseline data and the patient was able to
needs assist daily activities. the patient will be response to evaluation participate on
- HgB: 71g/l able to participate on supplemental activities actively.
Nomal range: activities actively. oxygen and
120-160 g/l medications.

Dependent:
1. Transfuse 2 u To supply blood and
PRBC as increase hemoglobin
ordered by the level
physician.
 ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS

Subjective Data: Ineffective breathing After 2-3 hours of Independent: After 2-3 hours of
“Nahihirapan akong pattern related to nursing interventions, 1. Monitor VS For baseline data nursing interventions,
huminga.” As altered oxygen supply the patient will be the patient was able to
verbalized by the as evidenced by short able to establish a 2. Encourage To help patient breath establish a normal
patient. rapid respiration and normal respiratory slower/ deeper easily respiratory pattern.
dyspnea. pattern. respirations,
Objective Data: use of pursed-
- RR: 24 cycle Rationale: lip technique.
per minute Ineffective breathing
- Uses of pattern because the 3. Elevate height To promote
accessory inspiration and/or of the bed. physiological/
muscles to respiration of the psychological ease of
breathe patient does not maximal inspiration.
- Short rapid provide adequate
respiration ventilation. Dependent:
- dyspnea 1. Administer To facilitate normal
oxygen at breathing pattern
lowest
concentration
indicated for
underlying
pulmonary
condition,
respiratory
distress or
cyanosis.