Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Fear related to After 4 hours of Independent: After 4 hours of

“Natatakot ako situational crisis. nursing •Review patient’s •Clarifies patient’s nursing
sakaramdaman interventions, the previous experience perceptions and interventions, the
ko”as verbalized patient will display with cancer. assist in patient was able to
bypatient. appropriate range identification of display appropriate
of feelings and fears and range of feelings
lessened fear. misconceptions and lessened fear.
Objective: based on diagnosis
• Increased tension. and experience with
• Restlessness. cancer.
• Hopelessness.
•V/S taken as •Encourage patient •Provides
follows: to share thoughts opportunity to
T: 37.2 and feelings. examine realistic
P: 92 fears and
R: 20 misconceptions
Bp: 110/90 about diagnosis.

•Maintain frequent •Provides assurance

contact with that patient is not
patient. Talk with alone or rejected
and touch patient as and fostering trust.
appropriate.

•Provide accurate, •Can reduce anxiety

consistent and enable patient
information to make decision
regarding diagnosis and choices based
and prognosis. on realities.
 •Explain •Accurate
procedures, information allows
providing patient to deal more
opportunity for effectively with the
questions and situation, thereby
honest answers. reducing anxiety
and fear.

•Promote calm, •Facilitates rest,

quiet environment. conserves energy,
and may enhance
coping abilities.

Collaborative:
•Refer for •May be useful
additional resources from time to time to
for counseling or assist patient in
support as needed. dealing with
anxiety.
Reference:www.scribd.com and nurseslabs.com
Nursing Care Plan
 Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective Impaired physical After 8 hours Independent After 8 hours
cues: mobility related to of rendering  Assist patient  To improve muscle of rendering
“sakit akong disease process appropriate to do active strength and joint appropriate
luyo ug” as (compression/destruction nursing ROM mobility nursing
verbalized by of nerve tissue, interventions exercises on interventions
the patient. infiltration of nerves or the patient the lower the patient
their vascular supply, will be able extremities. was able:
obstruction of a nerve to:
Objective pathway, inflammation)  Assess degree  Patient may be 1.
cues: 1. of mobility restricted by self-view Demonstrate
Demonstrate produced by or self- perception out increasing
-Received increasing injury or of proportion with function of the
patient lying function of the treatment and actual physical extremities.
on bed, extremities. note patient’s limitations requiring
awake, perception of interventions to
coherent, & immobility promote progress
responsive. toward wellness.

-Limited  Perform an  Indicates need for/

ROM assessment of effectiveness of
pain to interventions and may
include signal
location, development/resolution
characteristics of complications.
, onset/
duration,
frequency,
quality,
severity,
 grimacing ( 0
– 10 scale)
 Provide  To promote non-
comfort pharmacological pain
measures, management.
quiet
environment
and calm
activities
 Encourage  To distract attention
diversional and reduce tension
activities and
relaxation
techniques
such as
focused
breathing and
imaging

Dependent
 Administer  In order for the muscle
analgesics as to be more relax and
prescribed by relieves the pain
the physician.

Collaborative
 Consult with  To develop individual
physical or exercise or mobility
occupational program and identify
therapist as appropriate adjunctive
indicated. devices.
Reference:www.scribd.com and nurseslabs.com
Nursing Care Plan

Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Impaired urinary After 8 hours of 1. Record urinary 1. Sudden decrease in Goal partially met.
The patient elimination related nursing output; investigate urine flow may
verbalized to decreased urine intervention, the sudden indicate
difficulty of output. patient will reduce reduction/cessation obstruction/dysfunction
urinating with a pain scale of 7 to of urine flow. or dehydration.
pain scale of 7 out 4.
of 10. 2. Encourage 2. Maintain hydration
increased fluids & & good urine flow.
Objectives: maintain accurate
T= 36.2 C fluids.
BP= 100/60mmHg
P=67 bpm 3. Monitor BP & 3. Orthostatic
R=20 cpm HR. hypotension
&tachycardia suggest
(+) good skin hypovolemia.
turgor
(+) moist mucous 4. Note urine flow 4. Decreased flowmay
membranes & characteristics. reflect urinary retention
(+) stable weight within crease pressure
&VS in Upper Urinary Tract.
(+) sunken eyes
(+) conscious 5. Administer 5. Relieve pain
(+) clear speech medication as enhances comfort
indicated eg. &promotes rest.
Analgesic &
antibiotcs
 6. Monitor 6. To indicate
laboratory studies. urinalysis status.
Reference:www.scribd.com and nurseslabs.com