Nursing Priority #1

Assessment Nursing Diagnosis Planning/Objectives Interventions Rationale Evaluation

Subjective: Acute pain at the back After 8 hours of nursing Independent Independent: At the end of 8 hours of care, the
 Patient rated as evidenced by care, the patient will be patient is able to:
pain 5/10 complaints of pain with able to: a. Obtain client’s/significant a. To fully understand
 “Agay! Imong pain scale of 5/10, other’s (SO) assessment of client’s pain symptoms.  Rate pain 3/10
kamot kay sakit facial grimace General: pain to include location,  Verbalize less frequency
sa likod”  Report pain is characteristics, onset, and severity of back pain
 SO also controlled duration, frequency,  Demonstrate use of
reported that quality, and intensity. relaxation skills like deep
patient has Specific: Identify precipitating or breathing when pain
been  Rate pain 3/10 aggravating and relieving occurs.
complaining of  Demonstrate factors  Verbalized effectiveness of
back pain use of deep breathing exercises in
relaxation skills b. Perform pain assessment b. To demonstrate alleviating pain.
Objective: and diversional each time pain occurs. improvement in status
 Seen with facial activities such Document and investigate or to identify worsening
grimace as, deep changes from previous of underlying condition/
 Shows guarding breathing reports and evaluate developing
behavior exercises. results of pain complications.
 Verbalize interventions
methods that
alleviated the c. Provide or promote c. To temporarily alleviate
pain such as nonpharmacological pain pain
praying, management:
meditation, etc.
d. Identify ways to avoid or d. To reduce occurrence of
minimize pain. muscle tension

e. Encourage adequate rest e. to prevent fatigue that

periods. can impair ability to
manage or cope with
pain.
Dependent:
a. Note client’s attitude a. Client may have beliefs
toward pain and use of restricting use of
pain medications, including medications, may have
any history of substance a high tolerance for
abuse drugs because of recent
or current use, or may
not be able to take pain
medications at all if
participating in a
substance abuse
recovery program.
Nursing Priority #2

Assessment Nursing Diagnosis Planning/Objectives Interventions Rationale Evaluation

Subjective: Fatigue r/t anemia After 8 hours of nursing Independent: At the end of 8 hours of care, the
 Patient secondary to Chronic care, the patient will be a. Note daily energy a. This is helpful in patient is able to:
verbalizes Kidney Failure as able to: patterns determining
“kapoy akong evidenced by pattern/timing of  Reported improved sense
lawas” verbalizations of General: activity. of energy
 “Sige rana siyag tiredness, insufficient  Report improved  Perform activities tolerable
katulog.” As energy and altered sense of energy b. Encourage the client to b. To increase level of to him like eating on his
verbalized by concentration  Perform tolerable do whatever possible tolerated activity own with minimal
his daughter activities assistance
Objective: Specific: c. Avoid or limit exposure c. Temperature and  Verbalized “maayo na
 Patient shows  Verbalize reduction to temperature and humidity can greatly akong paminaw,” and
facial grimace of fatigue as humidity extremes impact energy levels “makabuhat nako og mga
when exerting evidenced by hilimuon sa akong makaya”
strength reports of d. Instruct d. To lessen patient’s  Verbalized “mas ni abtik na
 Drowsiness increased energy client/caregivers in fatigue akong mga lihok dae.”
 Slowed and ability to alternate ways of doing  Rated fatigue 3/10
movement perform tolerable familiar activities and
activities methods to conserve
ADLs  Verbalizes energy
Bathing = 4 improved or
Dressing = 4 increased reaction
Grooming = 4 time and e. Encourage engagement e. Participating in
Mouth care = 4 movement in diversional activities, pleasurable activities
Toileting = 4  Rate fatigue 3/10 avoiding both can refocus energy and
Transferring bed/chair = with ten as the overstimulation and diminish feelings of
4 highest feeling of under-stimulation sluggishness, and
Walking = 4 fatigue unhappiness that can
Climbing stairs = 4 accompany fatigue
Eating = 4 Dependent:
a. Review medication a. Many medications have
regimen/other drug the potential side effect
use. of causing
/exacerbating fatigue
Nursing Priority #3

Assessment Nursing Diagnosis Planning/Objectives Interventions Rationale Evaluation

Subjective: Self-care deficit r/t After 8 hours of nursing Independent: At the end of 8 hours of care, the
 Verbalized, weakness as evidenced care, the patient will be a. Assess cognitive a. To determine client’s patient is able to:
“kapoy akong by dependence in able to: functioning (e.g., ability to participate in
lawas dae og performing ADLs and memory, intelligence, care and potential to  Verbalize “presko na akong
maglisod ko og verbalizations of General: concentration, ability to return to normal paminaw,”
lihok” weakness.  Perform self-care attend to task) functioning or to  Perform self-care with
activities within learn/relearn tasks. assistance
Objective: level of own  Implement use of bigger
 Patient is ability clothes for easy dressing
dependent/need  Demonstrate
s assistance in techniques and b. Determine individual b. To incorporate into plan
performing lifestyle changes strengths and skills of of care enhancing
personal hygiene, to meet self-care the client likelihood of achieving
ADLs, and needs outcomes as well as to
bedside care Specific: determine the level of
activities  Determines patient’s own ability
ADLs activities that are
Bathing = 4 tolerable to him
Dressing = 4 like eating
Grooming = 4  Asks for c. To guide and help
Mouth care = 4 assistance from c. Perform or assist with patient in performing
Toileting = 4 nurse in meeting client’s needs needs
Transferring bed/chair = performing
4 personal hygiene,
Walking = 4 and ADLs. d. Provide privacy and d. To reduce anxiety and
Climbing stairs = 4  Implementing equipment within easy for easy access of things
Eating = 2 use of bigger reach during personal needed during activities
clothes for easy care activities.
dressing
e. Allow sufficient time for e. To encourage in
client to accomplish performing activities
tasks to fullest extent of
ability. Avoid
unnecessary
 conversation or
interruptions.

f. Instruct client to request f. To assist patient in

assistance when performing
needed, or stay with tasks/activities
client as dictated by
safety needs.

Dependent:
a. Review medication a. For possible effects on
regimen alertness/mentation,
energy level, balance
and, perception.

b. Assist with medication b. To guide patient with

regimen as necessary, intake of medications
encouraging timely use and to promote timely
of medications intake of medicine