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Nursing Care Plan

Diagnosis Analysis Goal and obj. Interventions Rationale Evaluation


Acute pain r/t Unpleasant sensory After 8 hrs. of nursing The client’s reported pain
inflammation of the and emotional intervention, the • Note location • As this can was relieved
pelvis experience arising client’s reported pain pain influence the
from actual or will decreased amount of
I- the patient potential tissue pain
verbalized: damage or described experienced
"sobrang sakit. lalo na in terms of such • Assess for
nung dinala ako dito damage; sudden or referred pain, • To help
mamatay matay ako sa slow onset of any as appropriate determine
sakit" intensity from mild to possibility of
" 9 kasi maskit tlaga severe with an underlying
lalo na pag anticipated or condition
nagagalaw" predictable end and requiring
duration of less than 6 treatment
O– months. • Accept client’s
- Has guarding description of • Pain is a
actions. pain subjective
- Restless experience
- Complains of • Monitor vital
pain signs
- Not properly • Usually altered
groomed in acute pain
• Note when
M – Rate of pain from pain occurs • To medicate
0-10 is 9. prophylactic
ally, as
appropriate
• Provide
comfort • To promote no
measures pharmacologic
al pain
management

• Encourage use • To distract


of relaxation attention and
techniques reduce tension
• Encourage • To prevent
adequate rest fatigue
periods

• Administer • To maintain
analgesics, as “acceptable”
indicated level of pain
Diagnosis Analysis Goal Interventions Rationale Evaluation
Activity intolerance It is a state in which a After the intervention - Encourage - to reduce The patient was able to
person has insufficient the patient will be able adequate rest cardiac verbalize and utilize
I- "hindi ako physical or to verbalize and utilize periods workload energy conservation
makagalaw ng maayos psychological energy energy conservation especially techniques.
dahil pag gumalaw ako to endure or perform techniques. before
sumasakit" desired physical ambulation and
activities this could be meals
related to any pain or
O- slow movement discomfort that a - Identify the - to promote rest
- needs support in patient feels activities the and energy
moving patient can conservation
- experience difficulty perform which
in doing certain actions are very
because of pain. essential to
refrain patient
from doing
Rate of pain from 0-10 nonessential
is 9. actions

- Anticipate
patient’s needs

- Assist with - to reduce


ADL as energy
indicated expenditure but
avoid doing
things for
patient we she
can still
perform to
increase
patients self-
esteem

- Teach patient - to prevent over


about exerting.
progressive
activity
Diagnosis Analysis Goal Interventions Rationale Evaluation
self care deficit This is a state in which Within the 8 hour shift - Encourage - To decrease The patient was able to
a person experience a the patient will be able independence patients perform self-care needs.
I - “hindi pa ako naliligo difficulty in to perform self-care but intervene frustration
simula nung dinala ako performing tasks of needs within patient’s when the
dito kasi ndi ako daily living, such as activity capability. patient cannot
masyadong makgalaw dressing, bathing, perform
ng maayos” toileting, transferring
from bed, and walking - Identify
0- not properly groomed patient’s
- With no activity
attending tolerance
significant
person to assist - Provide patient
the patient with positive
reinforcement
for attempted
activities

Dressing:
- Provide patient
privacy during
dressing

- Provide - To reduce
frequent energy
encouragement expenditure
and assistance and frustration
as needed with
dressing

- Plan possible - So patient will


daily activity be able to rest
prior to activity

- Encourage use - To ensure


of clothing one easier dressing
size larger and comfort

Hygiene:
- Encourage
patient to comb
hair