Dx:

Patient:
assessment
subjective
permanente
kona itong
dadalhin itong
mga sugat na
ito as
verbalized by
the patient
Objective
-Lack of eye
contact
-Hesitant in
sharing his
thoughts
-rejects
positive
feedback
about self
-frequently
talking to
significant
others

Room:
Nursing
diagnosis
Chronic low
self-esteem
related to
traumatic
situation

inference

planning

Intervention

Low selfesteem is
having a
generally
negative
overall
opinion of
oneself,
judging or
evaluating
oneself
negatively,
and placing a
general
negative
value on
oneself as a
person. In
patient
situation he is
in time where
he live more
in socializing
to other
people
wounds and
possible scar
may lead to
self-esteem

After the 8
hrs. of nursing
intervention
the patient
will be able
to:

Independent:

Verbalizing of
feeling of selfworth

Maintenance
of relationship
to significant
others

-Help client to
identify
environmental
factors which
increased risk for
low self-esteem.
-Encourage client
to verbalize
thoughts and
feelings about the
current situation.
-Implement
measures to
assist client to
increase selfesteem

- give positive
feedback about
accomplishments

Rationale

Evaluation

-Identification
is early stage
of problem
solving
process.

Afte 8 hrs of
nursing
intervention
the client was
able to :
The patient
were able to
Verbalized of
self of worth

-Allowing the
client to
clarify
thoughts and
feelings
promotes selfacceptance

Maintain of
relationship to
clients
significant
others

-Must limit
negative selfassessment,
encourage
positive
comments
about self,
assist to
identify
strengths

-To uplift

Dx:

Room:

Patient:
because it
alters his
condition and
his daily life
Assist client with
usual grooming
and makeup
habits if
necessary.
-Encourage visit
and support to the
clients significant
others

clients selfesteem to
assure that
there is
improvement

-having a
good hygiene
can also uplift
self esteem

-This is to
prevent the
total
withdrawal of
relationship to
is significant
others

Dx:

Room:

Patient:

Assessment

Nursing dx

inference

Planning

Subjective:
medyo
masakit and
likod as
verbalized by
the patient

Acute pain
related to

Pain is a
discomfort
that is caused
by the
stimulation of
the nerve
endings. Any
trauma that
the kidney
experience
(by any
causes or
factors)
perceive by
the body as a
threat, the
body releases
cytokine and
prostaglandin
causing pain
which is felt
by the patient

After 8 hours
of nursing
intervention
the client will
be able to:

Objective
-Facial
grimaces
-guarding
behavior
-Back pain/
flank area
-Limited ROM
-Diaphoresis
Pain scale5/10

Patient will
demonstrate
use of
different
relaxation
techniques to
relive pain

Nursing
intervention
Independent

Rationale

-establish rapport

-to gain client

trust

-Monitor vital sign

-obtain
baseline data

-Accept patient
description of pain

-pain is a
subjective
experience
and cannot be
changed

-Encourage
verbalization of
feeling

-to allow out

let for
emotions and
enhanced
coping
mechanism

-Provide quiet
environment,

-to prevent

Evaluation
After 8 hours
of nursing
intervention
the patient
was able to
demonstrate
use of
different
relaxation
techniques to
relive pain

Dx:

Room:

Patient:
Vital
signs/8:00 am
Bp
Rr
Pr
Temp

at his flank
area.

calm activities
and adequate rest
reinforcement
-Provide comfort
measures such as
back rub, use cold
or heat
-Instruct use of
relaxation
exercise such as
focus breathing

-Encourage
diversional
activity such as
TV and socializing
with others

Dependent
- Administer
analgesics
if indicated

fatigue and
lessen stimuli

-to provide
non
pharmacologic
al pain
management
-this is a form
of relaxation
technique that
helps to
decrease pain
level
-provides
diversionary
activities that
helps block
the perception
of pain

pharmacologic
management
for pain

Dx:

Room:

Patient:

Assessment

Nursing dx

Inference

Planning

Subjective:

Impaired
urinary
elimination
related
decrease
excretory
function of
renal system

Renal Failure
is a problem
which results
to loss of
kidney
functions and
as GFR
decrease, the
kidney cannot
excrete
nitrogenous
product and
fluid causing

After 8 hours of
nursing
intervention the
patient will be
able to

hirap po ako
umihe. As
verbalized by
the patient

Objective
Oliguria
Anuria

Patient will
participate in
measures to
correct/compen
sate for defects

Nursing
intervention
-Establish
rapport.

-Monitor and

Rationale

Outcome

To get the
cooperation of
the patient

After 8 hours
of nursing
intervention
the patient is
able to

To obtain
baseline data.

record vital signs

-Establish
realistic
activity goal

Enhance
commitments
to promoting
optimal
outcomes.

Participate in
measures to
correct/
compensate
for defects

Dx:
Patient:
Hesitancy in
urination
Urinary
Retention

Room:
impaired in
Urinary
elimination
and together
with
prolonged use
of medications
such as
NSAIDs this
will lead to
further kidney
destruction
which may
thus
decreasing
the glomerular
filtration and
destroying of
the remaining
nephrons. This
will result into
inability of the
kidney to
concentrate
urine which
makes the
patient to
have a
nursing
diagnosis of
impaired

with client.
To assess
degree of
interference.
-Determine
clients pattern
of elimination
-Palpate
bladder
-Note
condition of
skin and
mucous
membranes,
color of urine.

To assess
retention
To assess level
of hydration.

To help in
treating
urinary
alterations

-Observe for
signs of
infection

To promote
wellness.

-Emphasize

To promote

importance of

wellness.

having good
hygiene.
-Emphasize
importance of
adhering to

Dx:

Room:

Patient:
urinary
elimination

treatment
regimen