ASSESSMENT DIAGNOSIS S-May sugat ako sa Infection related to sakong as verbalized wound at the calf by the patient.

Objective wound at the calf

PLANNING INTERVENTION After all the nursing Establish interventions the Rapport patient will demonstrate techniques, lifestyle changes to promote safe environment and to prevent spread of Monitor vital signs infection.

RATIONALE To gain trust and cooperation of the patient

Stress proper hand washing techniques.

EVALUATION After all the nursing interventions the patient was able to demonstrate techniques, lifestyle changes to promote safe environment and To assess the to prevent spread of effectiveness of infection such as: nursing interventions Proper wound and obtain baseline care for future comparison Proper hand hygiene Disposal of garbage to proper A first- line defence container against nosocomial infections or cross contamination To promote wellness and for further wound healing For relief and

Advice the patient to eat nutritious foods Importance of

adherence to treatment regimen Instruct increase fluid intake Proper waste disposal

further wound healing For proper hydration To promote cleanliness and to prevent further infection To know if the patient really understand proper wound care

Demonstrate and allow return demonstration of wound care

ASSESSMENT S> Hindi siya gaanong makakilos dahil sumasakit ang tiyan niya. as verbalized by the patient. O> intolerance to activity > prescribed movement restriction > pain >facial grimace >restless >irritable >with guarding behavior

DIAGNOSIS Impaired physical mobility related to decreased muscle strength as manifested by limited ROM, and muscle weakness

PLANNING After all the nursing intervention the patient will demonstrate measures in increasing her mobility and will be able to used safety measures to minimize potential for injury

INTERVENTION Encourage participation in self-care and recreational activity Provide for safety measures, assist client to learn safety measures Encourage adequate intake of fluids/ nutritious foods Instruct to do deep breathing exercises Administer antibiotics as prescribed Encourage compliance to

RATIONALE To maintain position of function and reduce risk of pressure on affected part To enhance self-concept and sense of independence To promote well-being and maximize energy production

EVALUATION After all the nursing intervention the patient demonstrate measures in increasing her mobility and was able to used safety measures to minimize potential for injury

To relieve pain and to promote relaxation To prevent further infection For further healing

treatment regimen Emphasize proper To prevent further hand hygiene infection and transmission of microorganisms For wellness and proper nutrition

Eat nutritious foods like green leafy vegetables

ASSESSMENT S-masakit ang tiyan ko as verbalized by the patient. O> with facial grimace > fatigue > self narrowed >crying >irritable

DIAGNOSIS Acute pain related to

PLANNING After all the nursing interventions, the patient will demonstrate use of relaxation skills, other methods to promote comfort and to relieve pain.

INTERVENTION Assess reports of pain, including location and intensity (scale of 0-10). Observe nonVerbal cues.

RATIONALE To provide baseline information. Pain is unique to each patient.

EVALUATION After all the nursing interventions, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort and to relieve pain.

One may encounter varying descriptions because of individualized perceptions. Non verbal cues may aid in evaluation of pain and effectiveness of therapy.

Explore alternative pain relief measure like relaxation technique,

Cognitive behavioral interventions may reduce reliance on pharmacological

breathing techniques and guided imagery. Carefully position affected part.

therapy and enhance patients sense of control. Reduces discomfort, and risk for injury.

Apply local massage gently to affected areas. Encourage range of motion exercises.

Help reduce muscle tension.

Prevents joint stiffness and possible contracture formation.