Nursing Care Plan Tophi

Chapter 2
PLANNING
Rank Nursing Diagnosis Justification
Chronic Pain r/t joint This is our 1st prioritized problem because
inflammation evidenced by on Pain is considered as the 5th vital sign. And
and off pain for the past 20 years since all vital signs are crucial to determine
1 with a pain scale of 4/10 the state of the patient, this should be
addressed immediately.
This is the 2nd prioritized problem because it

Impaired Renal Perfusion r/t deals with the removal of toxic waste in the
accumulation of urate crystals in body. If excretion does not take place, then all
renal tubules as evidenced by toxic substance would remain in the body and
increased BUN, creatinine and go along with the circulation for a long period
2 uric acid level in laboratory of time which can cause fatal death.
results.
This is the 3rd prioritized problem because it

Impaired Tissue Integrity r/t affects the body’s circulation and according to
accumulation of urate crystals in the CAB principle, problems in circulation
3 joints and body tissues as should be given immediate interventions.
evidenced by presence of
infected, ulcerated tophi
Impaired Physical Mobilty r/t This is the 4th prioritized problem because it
pain as evidenced by limited affects the ADLs of the patient for meeting
4 ability to perform gross and fine basic needs.
motor skills
Disturbed Sleeping Pattern r/t This is the 5th prioritized problem because
pain as evidenced by reports of according to the Maslow’s hierarchy,
sudden attacks of pain on joints physiological needs should be addressed first.
at night Physiological needs include rest and sleep to
5
help the body repair and heal.
ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Activity Short-term outcome Independent:

“Masakit talaga siya. Intolerance After 2 hours of nursing 1. Assess patient’s ability to perform 1. Influences choice of interventions or Short-term outcome
Mga 20 years ago, r/t pain upon intervention, the patient ADLs noting difficulty in needed assistance. PARTIALLY ACHIEVED: After 2
1997 yun, standing as will be able: accomplishing task. 2. Adequate energy reserves are hours of nursing intervention, the
nadiagnose ako ng evidenced by - identify factors the 2. Assess the patient’s nutritional needed during activity. patient was able:
gouty arthritis tapos limited ability aggravate activity status. 3. Sleep deprivation and difficulties - identify factors the aggravate
katagalan nagsimula to perform intolerance. 3. Observe and monitor the patient’s during sleep can affect the level of activity intolerance.
na pumutok at may gross and fine sleep patter and amount of sleep activity of the patient. - verbalize and use energy-
- verbalize and use
lumalabas na nana. motor skills achieved over the past few days. 4. Assistive devices enhance the
energy-conservation conservation techniques.
Ngayon lang to 4. Assess the need for ambulation mobility of the patient to help him
techniques. - identify methods to reduce
lumala ng ganito” As aids for ADLs. overcome limitations.
verbalized by the - identify methods to 5. Encourage physical activity, 5. To help prevent muscle atrophy and activity intolerance
patient. reduce activity develop proper patient exercise strengthen the patients’
intolerance programs and ensure they are cardiovascular system. Physical Discharge Outcome:
Objective Data: followed regularly. activity can also have a positive PARTIALLY ACHIEVED: By
1. Facial grimace Reference: Discharge Outcome: 6. Evaluate patient recovery speed effect on the patients’ psychological discharge, the patient was able
during mobility Nurse’s By discharge, the between sessions status. to:
2. Pain scale of Pocket Guide patient will: 7. Instruct/encourage use of relaxation 6. In order to ensure proper scheduling - exhibit tolerance during
8/10 13th Edition - exhibit tolerance exercise such as focused breathing. and prevent additional overload or physical activity without the use
3. Joint by Doenges, during physical activity stress while the patient is still of assistive devices as evidence
inflammation Moorhouse without the use of 8. Eliminate nonessential activities or recovering from their previous by verbalizing no complaints of
4. Presence of and Murr pg assistive devices as procedures sessions. pain upon movement.
multiple tophi 663-670 evidence by verbalizing 9. Provide proper resting positions 7. To limit metabolic demands, - report ability to perform
5. no complaints of pain and postural exercises. maximize energy available for required activities of daily living.
upon movement. 10. Gradually increase activity with healing and meet comfort needs.
- report ability to active range-of-motion exercises in 8. To conserve energy output,
perform required bed, increasing to sitting and then conserve strength for important
activities of daily living. standing. activities and ensure adequate rest.
11. If appropriate maintain gradual 9. To maintain and improve joint
progression of activities function and flexibility.
10. Gradual progression of the activity
Collaborative: prevents overexertion.
12. Administer medications prescribed 11. To improve performance overtime.
by physician.
-Colchicine 0.5mg/tab OD;
- Paracetamol + Tramadol 325
g/tab 1 tab q8 for pain
* Refer for Surgical Intervention

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Chapter 2

Rank Nursing Diagnosis Justification

This is the 2nd prioritized problem because it

This is the 3rd prioritized problem because it

Subjective Data: Activity Short-term outcome Independent:

* Refer for Surgical Intervention

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