NURSING CARE PLANAssessmentDiagnosisPlanningInterventionsRationaleEvaluationSubjective data:Masakit po ang kaliwang tuhod ko, lalo na pag naigagalaw as verbalized by the patient.

Objective data:Pain scale of 7/10Facial grimaceGuarded movementsIrritabilityJoint swelling

Alteration in comfort: Acute pain related to compressed nerve endingsAfter 30 minutes of nursing intervention, the client will verbalize a decrease in pain sensation from 7/10 to 3/10 or belowEstablished trust and rapport

Encouraged verbalization of feelings about pain

Provided comfort measures such as touch, repositioning and use of cold compress

Encouraged relaxation technique such as deep breathing exercises

Encouraged diversional activities such as listening to music and socialization with others

Administered analgesic as orderedTo gain clients cooperation

To reduce fear and anxiety that may contribute to pain sensation

To promote nonpharmacological pain management

To distract attention on pain sensation and reduce tension

To reduce pain sensation through distraction

To maintain acceptable level of pain

Goal met, patients pain sensation is reduced as evidenced by patients verbalization of pain scale from 7/10 to 2/10.

AssessmentDiagnosisPlanningInterventionsRationaleEvaluationSubjective data:Half cup lang po ng rice ang nauubos ko kapag kumakain ako at di din po ako mahilig kumain ng gulay as verbalized by the patient.

Objective data:Weight loss from 24kg to 23.5kgBMI of 13.1Poor muscle tone

Imbalanced nutrition: less than body requirements related to food intake less than RDA After 1 hour of nursing intervention, patient will able to understand behaviors, lifestyle changes to regain and maintain appropriate weightEstablished trust and rapport

Assesses weight and recorded

Assessed eating habits including food preferences and tolerance

Encouraged to choose food preferences

Encouraged oral care before and after meal

Advised to continue in taking food supplements such as multivitamins and mineralsTo gain clients cooperation

To established baseline parameters

To appeal to patients likes and dislikes

To stimulate appetite

To avoid poor oral hygiene that may alter appetite

To meet nutrients that are not found in patients usual diet

Goal met, patient was able to understand behaviors, lifestyle changes to regain and maintain appropriate weight as evidenced by verbalization of patient to increase his food intake

AssessmentDiagnosisPlanningInterventionsRationaleEvaluationSubjective data:Nahihirapan po akong igalaw ang mga kasukasuan ko as verbalized by the patient.

Objective data:Stiffness on the jointsSwelling of the jointLimited range of motionPain on the joints during exertionUncoordinated movements

Impaired physical mobility related to musculoskeletal impairmentsAfter 1 hour of nursing intervention, patient will able to demonstrate and indentify techniques or behaviors that enable resumption of activitiesEstablished trusts and rapport

Instructed to support affected body parts or joints using pillows, foot supports and bandage

Encouraged rest in between activities

Encouraged participation in self-care

Encouraged range of motion exercises

Encouraged adequate intake of fluids and nutritious food To gain clients cooperation

To maintain position of function and reduce risk of pressures

To reduce fatigue

To enhance self-concept and sense of independence

To avoid complication of the affected side

Promotes well-being and maximizes energy production

Goal met, patient was able to demonstrate and identified techniques or behaviors that enable resumption of activities as evidenced by patient performs active and passive range of motion exercises

AssessmentDiagnosisPlanningInterventionsRationaleEvaluationSubjective data:Di ko magawa ng maayos yung dapat kong gawin dahil sa kalagayan ko as verbalized by the patient.

Objective data:Uncoordinated movementsStiffness of jointsPain during exertion in the jointsLimited range of motionPoor muscle tone

Activity intolerance related to musculoskeletal impairments as manifested by joint swelling and poor muscle tone

At the end of the shift, patient will able to report increase in activity toleranceEstablished trusts and rapport

Instructed to adjust activities

Encouraged to increase activity or exercise levels gradually

Encouraged rest in between activities

Provided positive atmosphere

Provided comfort measures and relief of pain

To gain clients cooperation

To prevent over exertion

To conserve energy

To conserve energy

To minimize frustration and rechannel energy

To enhance ability to participate in activities

Goal met, patient was able to demonstrate increase in activity tolerance as evidenced by patient able to transfer from bed to chair without assistance

AssessmentDiagnosisPlanningInterventionsRationaleEvaluationSubjective data:Nahihirapan po akong maligo as verbalized by the patient.

Objective data:Inability to wash body and get bath supplyDifficulty to put clothing Difficulty in handling eating utensils

Self-care deficit related to discomfortAfter the shift, the patient will able to perform self-care activities within level of own abilityEstablished trusts and rapport

Promoted patients participation in activities

Assisted patient in meeting his needs if he is unable to meet own needs

Provided for communication among those who are involved in caring and assisting for the patient

Encouraged energy-saving behaviors such as sitting instead of standing as possibleTo gain clients cooperation

To enhance self reliance and promote independence

Personal care assistance is part of nursing care and should not be neglected while promoting and integrating self-care independence

Enhances coordination and continuity of care

To conserve energy while performing self-care activities

Goal met, patient was able to perform self-care activities within normal level of own ability as evidenced by patient appears clean, neat, tidy and well groomed

Risk factorsDiagnosisPlanningInterventionsRationaleEvaluationLimited fluid intakeFrequent bleedingEcchymosisHemarthrosis

Risk for deficient fluid volumeAfter 1 hour of nursing interventions, the patient will able to understand behaviors or lifestyle changes to prevent development of fluid volume deficitEstablished trusts and rapport

Monitor intake and output

Assessed skin turgor and oral mucous membrane

Encourage to increase oral fluid intake

Noted clients age, current level of hydration and mentation

Administer IV fluids as prescribed To gain clients cooperation

To ensure accurate picture of fluid status

To monitor signs of dehydration

To promote hydration

Provides information regarding ability to tolerate fluctuations in fluid level and risk for creating or failing to respond to problem

To deliver fluids and promote hydration

Goal met, patient understood behaviors or lifestyle changes to prevent development of fluid volume deficit as evidenced by patients oral fluid intake is increased from 35ml/hr to 70ml/hr