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Nursing Diagnosis: Acute Pain r/t post BKA at right leg

Assessment Scientific Basis Planning Intervention Rationale Evaluation


Short Term: Independent: After 8 hours of
Subjective: Pain unpleasant After 30mins of -Instructed the To promote nurse-client
Sakit kaayo sa or hurtful nurse-client S.O to promote relaxation and intervention,
tumoy sa ako tuo sensation interaction, patient comfort measures ease pain. patient will have
will:
nga tiil kung resulting from (assist in improved comfort
K-understand that
mokalit ra ug stimulation of changing To have focus on level and
his altered level of
lihok as nerve endings. comfort is due to positions). other things and verbalizes a pain
verbalized by the The stimulus is the injury. - instructed decrease pain. score of 4/10.
patient. With a carried by nerve S- demonstrate patient to do deep
pain score of fibers to the techniques to breathing To divert
7/10. spinal cord and improve level of exercises attention from
then to the brain comfort -encouraged pain.
where the nerve A- show diversion
impulse is cooperation in the techniques like
interpreted as provision of nursing listening to music
care
Objectives: pain. The
Long Term:
excessive Dependent
After 8 hours of
-wound covered stimulation of nurse-client -Give pain To relieve pain
with dressing nerve endings interaction, client medications as and treatment of
-facial grimace during pain is will: indicated illness
- attributed to K-identify and
tissue damage. methods to improve
And in this sense levels of comfort Collaborative:
pain has S- show enhanced -collaborate to the To have proper
protective value. and improved levels nutrition staffs diet and to cope
Serving as a of comfort up with the
A- coordinate with
danger signal of metabolic
the nurse and s/o in
disease and often -collaborate with demands
providing comfort
facilitating measures the other utility
diagnosis. workers. To ease mind
from stressors
and reduce
irritability.
Nursing Diagnosis: Impaired Physical Mobility

Assessment Scientific Basis Planning Intervention Rationale Evaluation

A modification in
Short Term: Independent: After 8 hours of
Subjective: movement or After 30mins of -Execute passive or -Exercise enhances nurse-client
Ma/Sir, palihog ko mobility can either nurse-client active assistive increased venous intervention, patient
straight sa ako tiil be a transient, interaction, patient ROM exercises to return, prevents will have
ug as verbalized by recurring or more will: all extremities. stiffness, and
the patient. permanent dilemma. K-understand that maintains muscle Goals met
And when it occurs, his altered level of strength and
it becomes a comfort is due to the stamina. It also See updated
complex health care injury. avoids contracture laboratory works of
problem that S- demonstrate deformation, which patient maintained
Objectives: involves many techniques to can build up normal WBC range
-inability to move different members improve level of quickly and could
the left lower right of the health care comfort hinder prosthesis No signs of
extremities team. In fact, some A- show cooperation usage. infection. (e.g
-Present a safe
observed degree of immobility in the provision of swelling,fever/heat,
is very common in nursing care environment: bed rails -These measures Redness)
-restlessness most conditions Long Term: up, bed in down promote a safe,
such as stroke, After 4 hours of position, important secure
-dependent and leg fracture, multiple nurse-client items close by. environment and
unable to participate sclerosis, trauma, interaction, client may reduce risk
in activity and morbid obesity. will: for falls.
K-identify and -encouraged patient
-difficulty in tuning methods to improve to increase fluid -strengthens
levels of comfort intake immune system
-limited range of S- show enhanced
motion observed and improved levels -encouraged patient
of comfort to eat foods high in To promote wound
A- coordinate with protein and healing
the nurse and s/o in consume
providing comfort blenderized feeding
measures
Dependent
-Give medications
as prescribed -To help aid in
curing ailment and
Collaborative: infection
-collaborate to the
nutrition staffs -To cope up with the
health demands of
-collaborate to the the body
med tech for any
possible laboratory -To be updated of
exams. any changes in the
laboratory works
that would indicate
infection
Assessment Scientific Basis Nursing Planning Intervention Rationale Evaluatio
Diagnosis n
Subjectiv Fatigue is fatigue SHORT-TERM GOALS INDEPENDENT: 1. this is to After
e Data: physical and/or r/t injury After 30 of patient- 1. introduce self establish 8hours of
kapoy mental condition nurse interaction, to patient and s/o rapport and nurse-
paman exhaustion that patient will: promote client client
kaayo ako can be triggered K- understand that his cooperation interventi
lawas, as by stress, fatigue is related to his on,
verbalized medication, injury condition 2. determine 2. fatigue can patient
by the mental or degree of sleep be a reports
patient physical illness or S- perform ADLs and disturbances consequence improved
disease. It participate in desired of, and/or sense of
Objective is characterized b activities at level of exacerbated energy
Data : y a profoundlack ability by sleep
-decreased of energy, feeling deprivation
performanc s of muscle weak A- be participative
e ness, andslowed during the in 3. provide 3. participating
movements or ce recommended treatment diversion in pleasurable
-restless ntral nervous syst program activities and activities can
- lack of emreactions. Fati LONG-TERM GOALS avoid both refocus energy
energy gue can also trigg After 8 hours of effective overstimulation and diminish
-disturbed er serious mental nursing interventions, the and under feelings of
sleeping exhaustion. Persis patient will: stimulation tiredness
pattern tent fatigue can c K-identify and basis of
ause a lack ofmen fatigue and individual 4. assist client to 4. promotes
areas of control
tal clarity (or feeli identify sense of
ng of mental "fuz appropriate control and
S- be able to
ziness") coping behaviors improves self-
demonstrate, perform
difficulty concentr esteem
ADLs according to desired
ating, and in som energy levels
e cases,
memory loss. A- be positive towards
( http://medical- improving oneself in
dictionary.thefree performing activities
dictionary.com/fat without being fatigued
igue)

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