ASSESSMEnt DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: • Acute pain related to After 8 hours of proper 1. Assess the location, and
severe headache and nursing intervention the pt. duration of headache and
“Labad kaayo akong side effects of pain in the incision every 2 Goal partially met
will :
ulo miss as verbalized hours.
treatments secondary to
by the pt. report decreased pain as R- Sudden changes or severe
convexity meningioma pain may indicate increased ICT
evidenced by:
Objective: and should be reported to the
Scientific Bases
• Reported no doctor.
• Pain scale of Because the brain has no 2. Encourage verbalization of
discomfort,
7/10 feelings
pain receptors, brain
• Vital signs within R- Pain is subjective experience
• Moaning tumors themselves do and cannot be felt by others
not cause headache normal limits,
3. Observe non-verbal cues
• Appears pain. Headaches are • Negative symptoms and pain behaviours
agitated actually the result of the R-Observations may not be
growth of meningioma Verbalize non-pharmacologic congruent with verbal reports
• C beaten look 4. Monitor skin colour and
or tumor, its increasing methods that provide relief.
temperature and vital signs
• C facial grimace size can increase
R- this aspects are usually
pressure inside the skull altered in acute pain
• diaphoretic and related fluid build- 5. Provide comfort measures
up on pain-sensitive like touch, repositioning,
blood vessels and nerves use of hot and cold packs,
within the brain. nurse’s presence
R- to promote a non-
Source: pharmacologic pain
management
Hinkle & Cheever: 6. Instruct in and encourage
Brunner&Suddarth’s use of relaxation
techniques like focused
textbook of Medical –
breathing and imaging
Surgical Nursing R- To distract attention and
13thEdition:Vol. 2, reduce tension
pp.2052-2057 7. Identify ways or methods
of avoiding or minimizing
pain
R- to explore methods for
alleviation/control
8. Encourage adequate rest
periods
R- to prevent fatigue
9. Review ways to lessen pain,
including techniques such
as Therapeutic touch (TT),
biofeedback, and
relaxation skills.
R- To promote wellness

Dependent
1. Administer analgesics as
indicated to maximum
dosages as needed

Collaborative
1. Collaborative treatment of
underlying condition or
disease processes causing
pain and proactive
management of pain
R- to assist client to explore
methods for alleviation/control
of pain
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
OUTCOME
Subjective: Situational Low Self- After 8 hours of nursing 1. Assess the response, Goal Met
“ naka perwisyo na Esteem related to intervention the patient and the patient's
gyud kos akoang dependency, role will be able to: family's reaction to  Demonstrate
pamilya” as changes, changes in self-  Demonstrate disease and treatment. behaviours to
verbalized by the image R /: To simplify the
behaviours to restore positive
pt. process approach.
SB: restore positive 2. 2. Assess the self-esteem
Development of a self-esteem relationship between  Express positive
Objective:  Express positive appraisal
negative perception of patient and close family
 Not taking appraisal members.  Identify feelings
responsibility self-worth in response
to current situation.  Identify feelings R /: Support families and underlying
for self-care, and underlying helps in the healing dynamics for
lack of follow- process
Doenges, Moorhouse, dynamics for negative
through 3. Involve everyone
Murr, Nurse’s Pocketguide: negative perception of self
 Change in self- nearby in education
Diagnosis, Prioritized perception of self
perception/oth and home care
er’s perception Interventions, Rationales, planning.
of role 12ed, pp. 723-726 R /: Can ease the
burden on the handling
and adaptation at home
4. Give time / listen to the
things that become
complaints.
R /: continuous support
will facilitate the
adaptation process.
5. Encourage expression
of feelings, anxieties
R/: Facilitates grieving
the loss

6. Assist client to problem-

solve situation,
developing plan of
action and setting goals
 to achieve desired
outcome.
R/: Enhances
commitment to plan,
optimizing outcomes.
7. Mobilize support
system.
8. Provide client to practice
alternative coping
strategies, including
progressive socialization
opportunities
9. Encourage use of
visualization, guided
imagery, and relaxation
R/: To promote positive
sense of self
ASSESSMENT DIAGNOSIS
Subjective:
“ ma okay na ba kaha Knowledge Deficit:
ko ani Ma’am” as regarding condition,self-
verbalized by the pt. care and discharge needs
r/t lack of exposure and
Objectives: unfamiliarity about
 Frequent information resources
questioning
noted SB:
 Pt. is agitated
 Inaccurate A deficient knowledge is
follow-through commonly experienced by
of instruction individuals coping with
 Incorrect task medical diagnosis with
performance unfamiliar and often
 Questioning of
complex problems. Patients
members of
may have access to
health care
information or have
team
someone teaching them
but have difficulty in
understanding the
information. This lack of
information often causes
the client to misinterpret
information or forget
because of the disuse/ lack
of reinforcement for
correct use
Source:
Doenges, Moorhouse,
PLANNING INTERVENTION EVALUATION
OUTCOME
After 8hrs of proper 1. Ascertain level of
nursing intervention the pt knowledge, including Outcome criteria:
will be able to: anticipatory needs The was able to
 Exhibit increased R- to assess readiness to 1. Exhibit increased
interest and learn and individual learning interest and assume
assume needs. responsibility for own
responsibility for 2. Identify support persons learning by beginning to
own learning by requiring information look for information and
beginning to look 3. Provide information ask questions
for information relevant only to the 2. Verbalize
and ask questions situation understanding of
 Verbalize R- to prevent overload condition, disease process
understanding of 4. Provide positive and treatment
condition, disease reinforcement
process and R- Can encourage
treatment continuation of efforts
5. Use short, simple
sentences and concepts.
Repeat and summarize as
needed
R- to make it easy for the
patient to understand
6. Provide an environment
that is conducive to
learning
R- to facilitate learning
7. Begin with information
the client already knows
and move to what the
client does not know,
from simple to complex
R- Can arouse interest/limit
Murr: Nursing Care Plans:
Guidelines for
individualizing Client Care
Across the Life Span, 8th
Edition, pp. 865-867
sense of being overwhelmed.
8. Provide active role for
client in learning process
R- Promotes sense of control
over situation and is means
for determining that client is
assimilating and using new
information.
9.Provide information about
additional learning resources
R- May assist with further
learning and promote
learning at own pace
10. Render physical comfort
for the pt.
R-Ensuring physical comfort
allows pt. to concentrate on
what is being discussed or
demonstrated
11. Provide an atmosphere
of respect, openness,
collaboration and trust
R-Conveying respect is
important when providing
education to pt.
12. Encourage question
R-to facilitate open
communication
Theory Actual

Erick Erickson’s Psychosocial Theory The pt. is unable to work

anymore and spends most
Generativity VS Stagnation of the time resting. There is
(Adulthood 40-64) – This is the period of development during which reversibility of roles. Now
most people have children. People who are able to provide guidance her children does more of
or a legacy to the next generation feel a sense of purpose, while the task instead of her.
people who do not do so may feel stuck.

Significant relationship: Household, workmates

Freud’s Psychosexual Theory The pt. verbalized that she

was happy and have a
The Genital Stage successful marriage with her
Age Range: Puberty to Death husband. She also has a
good relationship with other
During the final stage of psychosexual development, the individual people
develops a strong sexual interest in the opposite sex. This stage
begins during puberty but last throughout the rest of a person's life.
Interest in the welfare of others grows during this stage.

Piaget's Theory: Cognitive Development The pt. was confused

especially because of her
Formal operational stage, which begins in adolescence and spans current situation. She asks a
into adulthood. lot of questions regarding
The final stage of Piaget's theory involves an increase in logic, the her situation but is willing to
ability to use deductive reasoning, and an understanding of abstract listen to health teachings
ideas. At this point, people become capable of seeing multiple imparted.
potential solutions to problems and think more scientifically about
the world around them
Kohlberg’s Theory of Moral Development The pt. is an active member
in their barangay and is
Level III-Postconventional Morality: always present activities.
Social Contract Orientation She mentioned that she
In this stage, the person looks at various opinions and values of values the opinions of her
different people before coming up with the decision on the morality family and relatives before
of the action. making a decision.

follows standards of society for the good of all people

Fowler's Stages of Faith Development During Hospitalization even

with her current situation
Stage 6 – "Universalizing" faith, or what some might call the pt. was still able to treat
"enlightenment". The individual would treat any person with her family the same way as
compassion as he or she views people as from a universal
she treated them before
community, and should be treated with universal principles of love
and justice.
Anatomy and Physiology