ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S> Mag-iisang buwan

nako dito tapos di pa rin
ako makagalaw masyado
kase nga hirap ako. as
verbalized by the client

O>
Alert, conscious,
coherent
Afebrile
Oriented to time,
place and
person.
Poor skin turgor
capillary refill
after 3 seconds
Muscle strength
of 3/5 on upper
and 2/5 on lower
extremities
Auscultated 5-6
borborygmic
sound in each
quadrant for 1
minute.
Tympany heard
@ each quadrant
w/ grade 2
pressure ulcer at
sacral area
w/Oxygen via
nasal cannula @
1 lpm
w/ heplock @ R
metacarpal
w/ suprapubic
Activity intolerance
secondary to
underlying process as
evidenced by verbal
report of weakness
Short Term Goal:
After 8 hours of nursing
intervention, patient
will be able to identify
negative factors
affecting activity
tolerance and able to
eliminate or reduce
their effects when
possible.

Long Term Goal:
After 2-3 days of
nursing intervention,
client will demonstrate
a decrease in
physiological signs of
intolerance.
INDEPENDENT:
>Monitored for
abnormal vital signs.
>Assessed the muscle
strength and ADL.
>Note client reports of
weakness, fatigue, pain,
difficulty accomplishing
task.
>Plan care to carefully
balance rest periods
with activities.
>Provide positive
atmosphere, while
acknowledging
difficulty of the
situation for the client.
>Encouraged
verbalization of
feelings.
>Provided comfort
measures such as
therapeutic touch and
quiet & clean
environment.
DEPENDENT:
>Check CBG and other
laboratory values.
>Administer
medications as
prescribed by the
doctor.
COLLABORATION:
>Collaborate with
dietician and other
health care team.

>Establish a baseline
data and check
patients condition.
>Check the functional
range.
>Symptoms may be
result or may
contribute to
intolerance of activity.
>To reduce fatigue



>To help in minimizing
frustration and
rechanneling energy

>To enhance ability to
participate in activities.
>To help patient to
relieve anxiety,
irritation and
uncomfortability to the
situation.
>Provide comfort and
safety.
>Check for abnormality
in the values.
>To relieve any possible
pain of discomfort.

>Modify the food and
other health services
appropriate to the pt.
Short Term Goal:
After 8 hours of nursing
intervention, patient
was able to identified
negative factors
affecting activity
tolerance and able to
eliminate or reduce
their effects when
possible.

Long Term Goal:
After 3 days of nursing
intervention, patient
was able to
demonstrated a
decreased in
physiological signs of
intolerance.
catheter to urine
bag
w/ edema on
upper & lower
extremities

BP: 130/70
T: 36.4
H: 107
R: 19

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S> Masakit na ang sugat
ko sa likod at tila ba hindi
ko maintindihan kung
kalian gagaling. as
verbalized by the client
O>
Alert, conscious,
coherent
Afebrile
Oriented to time,
place and
person.
Poor skin turgor
capillary refill
after 3 seconds
Muscle strength
of 3/5 on upper
and 2/5 on lower
extremities
Auscultated 5-6
borborygmic
sound in each
quadrant for 1
minute.
Impaired skin integrity
r/t physical
immobilization as
evidenced by grade 2
pressure ulcer
Short Term Goal:
After 8 hours of nursing
intervention, patient
will be able to
demonstrate
understanding of plan
to heal skin and
prevent re-injury
Long Term Goal:
After 2-3 days of
nursing intervention,
client will display
timely healing of
pressure sores without
complication.
INDEPENDENT:

> Assess site of skin
impairment and
determine cause


>Monitor site of skin
impairment at least
once a day for color
changes, redness,
swelling, warmth, pain,
or other signs of
infection. Determine
whether the client is
experiencing changes in
sensation or pain. Pay
special attention to
high-risk areas such as
bony prominences,
skinfolds, the sacrum,
and heels
> Monitor the client's


> To provide the basis
for additional testing
and evaluation to start
the assessment process

>To inspect systematic
& identify impending
problems early













>To avoid harsh
cleansing agents, hot
Short Term Goal:
After 8 hours of nursing
intervention, patient
was able to
demonstrated
understanding of plan
to heal skin and
prevent re-injury
Long Term Goal:
After 2-3 days of
nursing intervention,
client was able to
displayed timely
healing of pressure
sores without
complication.
Tympany heard
@ each quadrant
w/ grade 2
pressure ulcer at
sacral area
w/Oxygen via
nasal cannula @
1 lpm
w/ heplock @ R
metacarpal
w/ suprapubic
catheter to urine
bag
w/ edema on
upper & lower
extremities

BP: 130/70
T: 36.4
H: 107
R: 19
skin care practices,
noting type of soap or
other cleansing agents
used, temperature of
water, and frequency of
skin cleansing.
> Monitor the client's
continence status, and
minimize exposure of
skin impairment and
other areas of moisture
from incontinence,
perspiration, or wound
drainage.
> Do not position the
client on site of skin
impairment. If
consistent with overall
client management
goals, turn and position
the client at least every
2 hours. Transfer the
client with care to
protect against the
adverse effects of
external mechanical
forces such as pressure,
friction, and shear.

water, extreme friction
or force, or cleansing
too frequently




> Moisture from
incontinence
contributes to pressure
ulcer development by
macerating the skin




>To prevent further
pressure ulcer on the
site of impairment