Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data

“Sobrang sakit ng balakang ko.”

Pain scale: 10/10

Objective data

Guarding pain Facial grimace Irritability Self-focus restlessness

P-when movingQ- flunk painR-lumbar areaS-10/10T-30 min to 1 hour

BP: 160/90PR: 110RR: 28Temp: 37.9

Lab results: Urinalysis 5-10 hpf (pus cell)

RBC 1-5hpf

Altered comfort r/t inflammation of the bladder as manifested by guarding pain, irritability, facial grimace, self-focus and increased BP, PR, RR, temp.

STG

Within 30 mins of effective nsg intervention, the pain will decrease from 10/10 to 5/10.

LTG

After 2 to 3 days, the pain will be in a manageable manner and the patient will perform ADLs until discharge.

Independent

-Assess patients level of pain-Monitor VS.-accept client’s description of pain.-Provide comfort measures (e.g., touch, repositioning, use of heat or cold packs, nurse’s presence), quiet environment and calm activities.-Instruct/ encourage use of relaxation techniques such as focused breathing.-Encourage adequate rest periods.

Dependent

-Administer analgesic, as ordered.

-Administer IVF, as ordered.

-for baseline data-for baseline data.-Pain is a subjective experience and cannot be felt by others.-To promote nonpharmacological pain management.

-To distract attention and reduce tension.

-To prevent fatigue.

-To maintain acceptable level of pain.

-To promote adequate hydration.

>After 30 mins of effective nursing intervention, the pain decreased from 10/10 to 6/10. The goal was partially met.

>After 2 days, the patient verbalized that the pain relieved and it is in a manageable manner. Goal met.

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data

“Mataas ang blood sugar ko”

Objective data

Hgt = 504 mg/dL

Unstable blood glucose related to lack of adherence to Diabetes management and inadequate blood glucose monitoring as evidenced by Hgt of 504.

STG

Within 15 – 30 minutes of nursing interventions the patient will verbalize plan for modifying factors to prevent/minimize shifts in glucose level

LTG

Within 5 days of nursing interventions the patient will maintain glucose in satisfactory rangeLess than 120 mg/dL

Independent

Assess blood sugar level

Monitor VS.

Provide information on balancing food intake, antidiabetic agents, and energy expenditure

Review client’s diet, especially carbohydrate intake

Encourage client to read labels and choose foods described as having a low glycemic index (GI), higher fiber, and low fat content

Provide diet 2400 calories – 3 meals/2snacks

Instruct and encourage the client to have regular excercise

To monitor blood glucose level

For baseline data.

To gain adherence to therapy

Glucose balance is determined by the amount of carbohydrates consumed

These foods produce a slower rise in blood glucose

Proper diet decreases glucose level/insulin needs, prevents hyperglycaemic episodes, can reduce serum cholesterol level

To promote weight loss

>After 30 mins of effective nursing intervention, the pain decreased from 10/10 to 6/10. The goal was partially met.

>After 2 days, the patient verbalized that the pain relieved and it is in a manageable manner. Goal met.

Dependent

Administer antidiabetic medication as ordered. (Humulin)

Collaborative

Schedule consultation with dietician to restructure meal plan and evaluate food choices

Treats underlying metabolic dysfunction reducing hyperglycemia and promoting healing

Calories are unchanged on new orders but have been redistributed to 3 meals and 2 snacks

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data

“ Nahihirapan akong huminga”

Objective data-use of accessory muscles

-difficulty of breathing

-cough

-x ray result remarks pneumonia

-crackles

VS:

RR: 25

Ineffective airway clearance related to excessive mucus production as manifested by difficulty of breathing and cough

STGWithin 30 mins of effective nsg intervention, the secretion will be reduced

Independent

-Monitor VS especially RR

-evaluate cough and gag reflex and swallowing ability

-position head appropriately

-encourage deep breathing and cough exercises -encourage bed rest

-instruct client to have increase fluid intake

-teach and provide CPT-stand by oxygen tank

Dependent-Administer bronchodilator (ventolin) as ordered

Collaborative-refer to the respiratory therapist

-for baseline data.

- to determine ability to protect own airway

-For lung expansion

-To loosen secretions

-prevents and reduces fatigue

-To liquefy secretions

- to facilitate breathing- to loosen secretion- for emergency purposes

-to facilitate breathing

-to promote individual care

>After 30 mins of effective nursing intervention, the secretion was reduced. The goal was met!