ASSESSMENTNSG. DIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATION

Subjective:

Madanagan nak nga

maoperaan.As verbalized by

the pt.

Objective:

Poor eye contact

Restless

Facial tension

Anxiety related to

change in physical

integrity as evidenced

by verbalization Within 2 hours of rendering intervention, patient will identify ways to deal with anxiety Monitored and recorded v/s

Promoted expression of feelings and fears

Explained procedures Encouraged family member to treat client as before Serve as baseline data

Reduces anxiety

Reduces anxiety

Reassure client that has a role in the family has not been altered After 2 hours of rendering effective nursing intervention, the client expressed her feelings and participate in her health car.

Pre Operation

Pre - Operation

ASSESSMENTNSG. DIAGNOSISPLANNINGNSG. INTERVENTIONRATIONALEEVALUATION

Nalaing nakon agawid nakonAs verbalized by the pt.

Appeared strong

Normal V/S

C good appetiteWellness r/t effective therapeutic regimen as evidenced by strong in appearance normal v/s and c good appetiteWithin the shift of rendering nsg interventions, the pt maintain normal body functions NPI established

v/s monitored and recorded

advised to have enough rest

advised for follow up check up

advised to eat nutritious foods to gain fruits

to serve as base line data

to reduce fatique

to serve as basis for continuity of care

to maximize energy productionWith the S of rendering effective Nsg interventions, the pt maintained normal body functions.

Post Operation

ASSESSMENTNSG. DIAGNOSISPLANNINGNSG. INTERVENTIONRATIONALEEVALUATION

S > haan ko maigaraw unay toy sakak As verbalized by the pt.

O> irritable

noted with limited movement

Activity intolerance r/t fracture as manifested by irritability, noted c limited movementWithin the shift of rendering Nsg. Interventions, the pt. will be able to participate willingly & desired activities NPI established

v/s monitored

provided calm environment

advised to have adequate rest

encouraged active ROME

assisted c ADLs to gain trust

to serve as baseline data to reduce fatique and promote relaxation to reduce fatique

to maintain muscle strength to conserve energy & promote safetyWithin the shift of rendering effective Nsg. Implementations, the pt. was able to participate willingly in desired activities.

ASSESSMENTNSG. DIAGNOSISPLANNINGNSG. INTERVENTIONRATIONALEEVALUATION

S> Haan nak pay ket makapagnan As verbalized by the pt.

O> Teary eyes

worried face

Impared walking r/t to neuro muscular skeletal impairement as manifested by teary eyes and worried faceWithin the shift of rendering Nsg interventions, the pt. will be able to move about within environment as needed NPI established

v/s monitored and recorded

assisted pt. to do ROME

advised to have adequate rest

encouraged to eat nutritious foods

assisted c ADLs to gain trust

to serve as baseline data

to promote circulation

to reduce fatique

to maximize energy production

to ensured safetyWithin the shift of rendering effective Nsg. Implementations, the pt. was able to move about c in environment as needed.

Post Operation

ASSESSMENTNSG. DIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATION

S: nasakit toy sakak no magaraw As verbalized by the pt.

O: Limited ROM slowed movement

irritability

V/SBP 120/80 mmhgPR 87 bpmRR 21 cpmTo 36.2 OC

Impaired physical mobility r/t surgical pain secondary to post surgical operation as manifested by limited ROMAt the end of the shift, the patient will be able to demonstrate, techniques/behaviors resumption of activities V/S monitored

Assisted in repositioning of the patient

Encouraged pts. To do movement within the limit of his ability For baseline data

To maintain position of function

To promote optimum level of functionAt the end of the shift, the patient demonstrated techniques/behaviors that enable resumption of activities.