Documente Academic
Documente Profesional
Documente Cultură
DIAGNOSIS
SUBJECTIVE: Acute Pain After 8 hours of shift, Perform To know the Goal Met: After 8 hours of
“Masakit ang related to patient will exhibit comprehensive severity and shift, patient was able to
ulo at batok physical wellness, as evidence assessment of cause of the exhibit wellness as evidenced
ko.”AVB the discomfort by: pain. pain by:
patient. secondary to Rated pain as Determine Able to rate pain as
Rated pain HPN. 3/10 from possible causes 3/10 from 6/10, 10
as 6/10, 10 6/10, 10 being of pain. being the highest.
being the the highest. Absence of facial
highest. Absence of Assess client’s To know how to grimace.
facial grimace perception of deal and what Absence of guarding
OBJECTIVE: Absence of pain noting to give the behavior.
With facial guarding attitude towards patient for the Verbalization of feeling
grimace. behavior. pain and use of pain felt. of relief.
With Verbalization specific pain No longer restless
guarding of feeling of relievers. No longer irritable
behavior. relief. Able to communicate
Restless No longer Note client’s Individuals with well with good
Irritable restless. control over external locus of attention.
Seems to No longer responsibility for control may
have less irritable. pain take or no
attention Able to management. responsibility
span when communicate for pain
being asked. well with good management.
Seems not attention.
attentive and Perform pain To rule out
cooperative. assessment each worsening/deve
time pain occurs. loping
complication.
Instruct/encoura To divert
ge relaxation attention and
exercise (deep promote
breathing relaxation.
exercise,
massage).
Administer To maintain
analgesic as acceptable level
indicate. of pain.
ASSESSMENT NURSING PLAN GOAL NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIION
SUBJECTIVE: Noncompliance After 3 days of home Discuss with To be able to be GOAL MET: Patient was able
“ Minsan kasi to medication visit, patient will client their aware of to manifest/demonstrate
nakakalimutan ko intake related manifest/demonstrate perception/un patient’s progress in condition and
uminom ng gamot at to adherence progress in condition derstanding of perception on understood need for
kasi nga wala naman to the and understood need the situation. medication. compliancy as evidenced by:
akong nararamdaman medication for compliancy as Patient is more
na dapat ako inom ng regimen. evidenced by: Listen attentive and concern
gamot”, as verbalized by Patient is more to/active- Knowing and about health.
the patient. attentive and listen client’s accepting
concern about complaints, client’s Reports on religious
OBJECTIVE: health. comments. perception and intake of medication
Seems to be not Reports on assessing and its importance.
attentive when religious intake client’s
taking of of medication knowledge on No longer agitated
medication is and its his/her when asked about
reinforced. importance. acceptance of medication intake.
Failure to take No longer medication
medications or agitated when regimen.
maintenance on asked about
time/religiously. medication Be aware of
Seems agitated intake. developmenta Sometimes
when asked l level as well chronoligical
about taking as age does not
medications. chronological coincide with
age of client. patient’s
perception or
knowledge.
Assess
availabilities To know and be
of support aware of
systems and patient’s
resources. support system.
Encourage To improve
client for self- abilities.
care,
providing for
assistance
when
necessary.
Accept client’s
evaluation of
own
strengths/limi
tations while
working with
client.
Have client
paraphrase Helps validate
instructions/in client’s
formation understanding
heard. and reveals
misconception.
Reinforced
importance of To attain
following progress and
medication health
regimen. developments.