Assessment Diagnosis Planning Intervention Evaluation

• 65 years of Age Impaired physical Short Term: Independent: Goals are met.
Mobility as evidence Within 8 hours:
Subjective: by joint stiffness and 1. Palpate the area of Patient’s pain is
From Patient: pain risk for • Pain scaled from Pain. Alleviated.
Arthritis.
• Fatigue
• Malaise, sore
1-10. 10 as
maximum.
 To determine the Patient’s joints
area’s diameter of display a normal
and stiff joints.
Long Term: infection. ROM and are
Objective:
Within 2 days: functioning well.
• Fatigue, Malaise, 2. Ask the Patient to
sore and stiff scale the Pain from 1-
• Patient Patient’s
joints are 10.
verbalizes no temperature
symptoms for
possible presence of pain.  To determine the displays as 36 C.
arthritis. • Patient displays patient’s level of pain
no signs of stiff Patient verbalizes
endured. no presence of
Subjective: joints and sore
joints. pain.
From Wife: 3. Put ice-pack on
• Low grade-fever • Patient’s affected area.
• Losing of weight temperature will
have 36-37 C.  To numb the pain.
Objective: • Patient’s Pain will
Fever is a possible sign be alleviated to a 4. Perform physical
for infection. pain scale of 0. assessment on vital
signs.
*DIAGNOSED with
possible Arthritis*
 To determine the level
of fever.

5. Ask the patient to

stand and record the
findings
 To document the
patient’s weight and
compare it to any old
record to determine if
the patient has indeed
lost weight.
Collaborative:
Dietary management:

1. Educate patient to
drink plenty of Milk.
 Calcium helps fortify
the patients bones and
risk for osteoporosis.

2. Increase Fluid intake.

 Fluids can help the
patient’s fluid balance.

Independent:
6. Administer
medications for Pain
relief and Fever
control.
 To control the patient’s
fever and pain
endured.