Chapter 2
PLANNING
Rank Nursing Diagnosis
Chronic Pain r/t joint
inflammation evidenced by on
and off pain for the past 20 years
1 with a pain scale of 4/10
Impaired Renal Perfusion r/t
accumulation of urate crystals in
renal tubules as evidenced by
increased BUN, creatinine and
2 uric acid level in laboratory
results.
Impaired Tissue Integrity r/t
accumulation of urate crystals in
3 joints and body tissues as
evidenced by presence of
infected, ulcerated tophi
Impaired Physical Mobilty r/t
pain as evidenced by limited
4 ability to perform gross and fine
motor skills
Disturbed Sleeping Pattern r/t
pain as evidenced by reports of
sudden attacks of pain on joints
at night
5
Justification
This is our 1st prioritized problem because
Pain is considered as the 5th vital sign. And
since all vital signs are crucial to determine
the state of the patient, this should be
addressed immediately.
This is the 2nd prioritized problem because it
deals with the removal of toxic waste in the
body. If excretion does not take place, then all
toxic substance would remain in the body and
go along with the circulation for a long period
of time which can cause fatal death.
This is the 3rd prioritized problem because it
affects the body’s circulation and according to
the CAB principle, problems in circulation
should be given immediate interventions.
This is the 4th prioritized problem because it
affects the ADLs of the patient for meeting
basic needs.
This is the 5th prioritized problem because
according to the Maslow’s hierarchy,
physiological needs should be addressed first.
Physiological needs include rest and sleep to
help the body repair and heal.
 ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS

Subjective Data: Activity Short-term outcome Independent:

“Masakit talaga siya. Intolerance After 2 hours of nursing 1. Assess patient’s ability to perform 1. Influences choice of interventions or Short-term outcome
Mga 20 years ago, r/t pain upon intervention, the patient ADLs noting difficulty in needed assistance. PARTIALLY ACHIEVED: After 2
1997 yun, standing as will be able: accomplishing task. 2. Adequate energy reserves are hours of nursing intervention, the
nadiagnose ako ng evidenced by - identify factors the 2. Assess the patient’s nutritional needed during activity. patient was able:
gouty arthritis tapos limited ability aggravate activity status. 3. Sleep deprivation and difficulties - identify factors the aggravate
katagalan nagsimula to perform intolerance. 3. Observe and monitor the patient’s during sleep can affect the level of activity intolerance.
na pumutok at may gross and fine sleep patter and amount of sleep activity of the patient. - verbalize and use energy-
- verbalize and use
lumalabas na nana. motor skills achieved over the past few days. 4. Assistive devices enhance the
energy-conservation conservation techniques.
Ngayon lang to 4. Assess the need for ambulation mobility of the patient to help him
techniques. - identify methods to reduce
lumala ng ganito” As aids for ADLs. overcome limitations.
verbalized by the - identify methods to 5. Encourage physical activity, 5. To help prevent muscle atrophy and activity intolerance
patient. reduce activity develop proper patient exercise strengthen the patients’
intolerance programs and ensure they are cardiovascular system. Physical Discharge Outcome:
Objective Data: followed regularly. activity can also have a positive PARTIALLY ACHIEVED: By
1. Facial grimace Reference: Discharge Outcome: 6. Evaluate patient recovery speed effect on the patients’ psychological discharge, the patient was able
during mobility Nurse’s By discharge, the between sessions status. to:
2. Pain scale of Pocket Guide patient will: 7. Instruct/encourage use of relaxation 6. In order to ensure proper scheduling - exhibit tolerance during
8/10 13th Edition - exhibit tolerance exercise such as focused breathing. and prevent additional overload or physical activity without the use
3. Joint by Doenges, during physical activity stress while the patient is still of assistive devices as evidence
inflammation Moorhouse without the use of 8. Eliminate nonessential activities or recovering from their previous by verbalizing no complaints of
4. Presence of and Murr pg assistive devices as procedures sessions. pain upon movement.
multiple tophi 663-670 evidence by verbalizing 9. Provide proper resting positions 7. To limit metabolic demands, - report ability to perform
5. no complaints of pain and postural exercises. maximize energy available for required activities of daily living.
upon movement. 10. Gradually increase activity with healing and meet comfort needs.
- report ability to active range-of-motion exercises in 8. To conserve energy output,
perform required bed, increasing to sitting and then conserve strength for important
activities of daily living. standing. activities and ensure adequate rest.
11. If appropriate maintain gradual 9. To maintain and improve joint
progression of activities function and flexibility.
10. Gradual progression of the activity
Collaborative: prevents overexertion.
12. Administer medications prescribed 11. To improve performance overtime.
by physician.
-Colchicine 0.5mg/tab OD;
- Paracetamol + Tramadol 325
g/tab 1 tab q8 for pain

* Refer for Surgical Intervention