Case
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ASSESSMENT
DIAGNOSIS
PLANNING
NURSING INTERVENTIONS
Subjective Data: “Masakit ang sugat ko.” As verbalized by the patient.
Acute pain related to tissue damage as manifested by facial grimace and pain scale of 6/10.
After 3-4 hours of nursing interventions, the pain scale of the patient will decrease from 6 to 2.
Independent: 1. Assess the patient’s pain including the location, characteristics, onset/duration, frequency, quality, severity and aggravating factors. 2. Assess for referred pain.
Objective Data: - facial grimace - crying - guarded or protective behavior - pain scale of 6/10 - reduced interaction with people and environment - presence of wound with pus
Rationale: Acute pain because the patient has wound caused by tissue damage. And the pain that the patient feels doesn’t exceeds for more than 6months.
RATIONALE
For baseline data
To help determine possibility of underlying condition or organ dysfunction requiring treatment.
3. Monitor VS
For baseline data
4. Provide comfort measures (e.g back rub, change of position) 5. Encourage diversional activities (e.g TV/radio)
To provide nonpharmacological pain management
Dependent: 1. Administer analgesics as prescribed by the physician.
To divert the patient’s mind in interaction of pain
To help the patient lessen the pain
EVALUATION After 3-4 hours of nursing interventions, the pain scale of the patient decreased from 6 to 2.
ASSESSMENT Subjective Data: “Nanghihina ako.” As verbalized by the patient. Objective Data: - pallor appearance - inability to move especially when she sits or stand up, needs assist - HgB: 71g/l Nomal range: 120-160 g/l
DIAGNOSIS
PLANNING
NURSING INTERVENTIONS
Activity intolerance related to imbalance between oxygen supply and demand as evidenced by decreased hemoglobin- 71g/l.
Shot-term Goal: After 4 hours of nursing interventions, the patient will be able to perform activities without experiencing fatigue, dizziness or weakness.
Independent: 1. Assess degree of mobility.
Rationale: Activity intolerance because the patient doesn’t have enough energy to perform her daily activities.
Long-term Goal: After 1 week of nursing interventions, the patient will be able to participate on activities actively.
RATIONALE
To identify proper nursing intervention
2. Encourage patient to rest in between activities.
To reduce fatigue and conserve energy
3. Assist with activities.
To protect patient from injury
4. Monitor response to supplemental oxygen and medications.
For baseline data and evaluation
Dependent: 1. Transfuse 2 u PRBC as ordered by the physician.
To supply blood and increase hemoglobin level
EVALUATION Short-term Goal: After 4 hours of nursing interventions, the patient was able to perform activities without experiencing fatigue, dizziness or weakness. Long-term Goal: After 1 week of nursing interventions, the patient was able to participate on activities actively.
ASSESSMENT Subjective Data: “Nahihirapan akong huminga.” As verbalized by the patient. Objective Data: - RR: 24 cycle per minute - Uses of accessory muscles to breathe - Short rapid respiration - dyspnea
DIAGNOSIS
PLANNING
Ineffective breathing pattern related to altered oxygen supply as evidenced by short rapid respiration and dyspnea.
After 2-3 hours of nursing interventions, the patient will be able to establish a normal respiratory pattern.
Rationale: Ineffective breathing pattern because the inspiration and/or respiration of the patient does not provide adequate ventilation.
NURSING INTERVENTIONS Independent: 1. Monitor VS
RATIONALE
For baseline data
2. Encourage slower/ deeper respirations, use of pursedlip technique.
To help patient breath easily
3. Elevate height of the bed.
To promote physiological/ psychological ease of maximal inspiration.
Dependent: 1. Administer oxygen at lowest concentration indicated for underlying pulmonary condition, respiratory distress or cyanosis.
To facilitate normal breathing pattern
EVALUATION After 2-3 hours of nursing interventions, the patient was able to establish a normal respiratory pattern.
DIAGNOSIS
PLANNING
NURSING INTERVENTIONS
Subjective Data: “Masakit ang sugat ko.” As verbalized by the patient.
Acute pain related to tissue damage as manifested by facial grimace and pain scale of 6/10.
After 3-4 hours of nursing interventions, the pain scale of the patient will decrease from 6 to 2.
Independent: 1. Assess the patient’s pain including the location, characteristics, onset/duration, frequency, quality, severity and aggravating factors. 2. Assess for referred pain.
Objective Data: - facial grimace - crying - guarded or protective behavior - pain scale of 6/10 - reduced interaction with people and environment - presence of wound with pus
Rationale: Acute pain because the patient has wound caused by tissue damage. And the pain that the patient feels doesn’t exceeds for more than 6months.
RATIONALE
For baseline data
To help determine possibility of underlying condition or organ dysfunction requiring treatment.
3. Monitor VS
For baseline data
4. Provide comfort measures (e.g back rub, change of position) 5. Encourage diversional activities (e.g TV/radio)
To provide nonpharmacological pain management
Dependent: 1. Administer analgesics as prescribed by the physician.
To divert the patient’s mind in interaction of pain
To help the patient lessen the pain
EVALUATION After 3-4 hours of nursing interventions, the pain scale of the patient decreased from 6 to 2.
ASSESSMENT Subjective Data: “Nanghihina ako.” As verbalized by the patient. Objective Data: - pallor appearance - inability to move especially when she sits or stand up, needs assist - HgB: 71g/l Nomal range: 120-160 g/l
DIAGNOSIS
PLANNING
NURSING INTERVENTIONS
Activity intolerance related to imbalance between oxygen supply and demand as evidenced by decreased hemoglobin- 71g/l.
Shot-term Goal: After 4 hours of nursing interventions, the patient will be able to perform activities without experiencing fatigue, dizziness or weakness.
Independent: 1. Assess degree of mobility.
Rationale: Activity intolerance because the patient doesn’t have enough energy to perform her daily activities.
Long-term Goal: After 1 week of nursing interventions, the patient will be able to participate on activities actively.
RATIONALE
To identify proper nursing intervention
2. Encourage patient to rest in between activities.
To reduce fatigue and conserve energy
3. Assist with activities.
To protect patient from injury
4. Monitor response to supplemental oxygen and medications.
For baseline data and evaluation
Dependent: 1. Transfuse 2 u PRBC as ordered by the physician.
To supply blood and increase hemoglobin level
EVALUATION Short-term Goal: After 4 hours of nursing interventions, the patient was able to perform activities without experiencing fatigue, dizziness or weakness. Long-term Goal: After 1 week of nursing interventions, the patient was able to participate on activities actively.
ASSESSMENT Subjective Data: “Nahihirapan akong huminga.” As verbalized by the patient. Objective Data: - RR: 24 cycle per minute - Uses of accessory muscles to breathe - Short rapid respiration - dyspnea
DIAGNOSIS
PLANNING
Ineffective breathing pattern related to altered oxygen supply as evidenced by short rapid respiration and dyspnea.
After 2-3 hours of nursing interventions, the patient will be able to establish a normal respiratory pattern.
Rationale: Ineffective breathing pattern because the inspiration and/or respiration of the patient does not provide adequate ventilation.
NURSING INTERVENTIONS Independent: 1. Monitor VS
RATIONALE
For baseline data
2. Encourage slower/ deeper respirations, use of pursedlip technique.
To help patient breath easily
3. Elevate height of the bed.
To promote physiological/ psychological ease of maximal inspiration.
Dependent: 1. Administer oxygen at lowest concentration indicated for underlying pulmonary condition, respiratory distress or cyanosis.
To facilitate normal breathing pattern
EVALUATION After 2-3 hours of nursing interventions, the patient was able to establish a normal respiratory pattern.
