Assessment

Subjective:
masakittalaga
tong
nararamdamanko
as verbalized
by the patient.

Objective:
- Guarding
behavior,
protecting
body part
- (+) facial
grimace
- (+) irritability
Vital Signs taken
as follows:
BP=130/80
T=36.9
P=88
R=24

Diagnosis
Acute Pain
related to disease
process as
evidenced by
non-verbal cues
such as (+)
guarding and
facial grimace.

Planning
After 4 hours of
nursing
intervention, the
client will report
that pain is
relieved and
controlled.

Intervention
- Assess the
level of pain,
location and
scale of pain,
perceived
client.

Observation
of vital signs
every 8 hours.

Instruct client
to perform
relaxation
techniques

Rationale
- Knowing the
level of pain
that is felt so
it can help
determine
appropriate
interventions.
-

Changes in
vital signs,
especially
temperature
and pulse rate
is one
indication of
increased pain
experienced
by the client.

Relaxation
techniques
can make the
client feel
comfortable
and a little
distraction to
divert the
attention of
clients to pain
so that they

Evaluation
Goal Met. After 4
hours of nursing
intervention, the
client reports that
pain is relieved
and controlled.

can help
children
reduce the
pain.

Provide a
comfortable
position.
-

a comfortable
position to
avoid an
emphasis on
the area of
injury pain.

Analgesic
drugs block
the pain
receptors so
that the pain
cannot be
perceived.

Collaboration
of analgesic
medication.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective:
Hindi
akomakagalawngma
ayos,
kasimasakitangtyan
ko as verbalized by
the patient.

Activity
Intolerance relat
ed to general
weakness,
imbalance
between supply
and oxygen
demand.

After 8 hours of
nursing
interventions the
client will
demonstrate a
decrease in
physiological
signs of
intolerance
(e.g., blood
pressure remain
within
clients normal
range).

-Monitor
vital/cognitive
signs, watching
for changes in
blood
pressure, heart
and respiratory
rate; note skin
pallor and/or
cyanosis, and
presence of
confusion.

Goal Partially
Met. After 8
hours of nursing
interventions the
client was able
to demonstrate
a decrease in
physiological
signs of
intolerance
(e.g., blood
pressure remain
within
clients normal
range).

Objective:
- Paleness
- Warm and dry
skin
- Generalized

-Determining the
cause of
intolerance
activity and
determine
whether the
cause of the

To obtain
baseline
parameters.

-Determining the
cause can help
determine
intolerance.

weakness
Vital Signs taken as
follows:
BP=130/90
T=37.2
P=83
R=24

physical,
psychological /
motivation.
-Assess the
suitability of
activity and rest
every day.
- Evaluate
current
limitations/degre
e of deficit in
light of usual
status.

Assessment
Subjective:
nanghihinaako,
natatakotakosapwedengmangyarisakal
agayanko as verbalized by the patient.

Objective:
- Pallor
- Cyanosis
- Difficulty of breathing
- Generalized weakness
Vital Signs taken as follows:

Diagnosis
Anxiety related to
Threat to or change
in health status
[progressive/debilit
ating
disease, terminal
illness], interaction
patterns, role
function/
status,
environment
[safety], economic
status.

Planning
After 24
hours of
nursing
interventi
on, the
patient
will
verbalize
awareness
of feelings
of anxiety.

-Prolonged
bedrest can
contribute to
activity
intolerance.
-Provides
comparative
baseline.

Intervention
- Assess
the level
of
anxiety,
the
factors
that
influence
the onset
of
anxiety.

Rationale
- Prelimina
ry data
of
anxiety
is
necessar
y to
determin
e the
clients
level of
anxiety
and the
factors

Evaluation
Goal
Partially
Met. After
24 hours
of nursing
interventi
on, the
patient
was able
to
verbalize
awareness
of feelings
of anxiety.

BP=130/90
T=37.2
P=83
R=24
-

Encourag
e clients
to
express
their
feelings,
fears and
perceptio
ns.

Assess
the
clients
expectati
ons to
treatmen
t and
care.
Understa
nd the
clients
perceptio
n of
stressful

affecting
it can be
seen that
the nurse
can
minimize
/ prevent
clients
from
influentia
l factor.
Presence
and
readines
s of
nurses in
handling
/
accompa
ny client
during
the
period of
anxiety
can help
clients to
fulfil a
sense of
security
so as to
reduce
anxiety.
The

situations
.

presence
of the
family
can
provide
mental
support
to
clients.
Relaxatio
n
techniqu
es can
reduce
stress
arising.