ASSESSMENT DIANOSIS PLANNING INTERVENTION EVALUATION

Subjective: “Sobrang Acute Pain r/t After 3 hours of nursing Independen:t After 3 hours of
sakit po ng likod ko” as inflammatory process intervention the patient Assess client pain, location, nursing
verbalized by the patient. will report pain is duration, characteristics, intervention the
relieve/ controlled. frequency, quality, intensity and patient was able
precipitating factors to report pain is
relieve/ controlled
Objective: use of pain scale appropriate for as manifested by:
age to evaluate the pain
Pain scale of 7/10 Pain scale of 5/10
Facial grimace Encourage the client’s to Calm
malaise verbalize and describe pain. relax
Restlessness
Irritable observe nonverbal cues/pain
Sleep disturbance behavior

provide comfort measures

(repositioning, touch, use of
hot/cold compress)

encourage patient use of

relaxation techniques such as
breathing exercise, adequate rest
and sleep

encourage diversional activities

( TV, Radio, socialization with
other friends

Dependent
Administer medication
prescribe.
Review laboratory result
ASSESSMENT
Subjective: ” hindi po ako
makakilos ng maayos kasi po
masakit ang kanan binti at
likod ko” as verbalized by the
patient
Objective:
Limited range of motion
Limited ability to perform gross
motor skills
Postural instability
Discomfort when movement
DIAGNOSIS
Impaired physical mobility
related to pain/ discomfort level
0 participate in ADLs and desired
PLANNING
After 8 hours of nursing
intervention the patient will
activities
INTERVENTION
Independent:
Assess the degree of immobility
Assist the client reposition self
on a regular schedule as by
individual situation
Support affected body parts
using pillow to maintain
position of function and reduce
risk of pressure ulcer
Provide safety measure, side
rails
Encourage patient participation
in self-care activities
Dependent:
Assist with treatment of
underlying condition causing
pain or dysfunction

Administer prescribe medication

Review laboratory result

Collaborative:

Encourage patient to have a

weekly therapy and
rehabilitation for further motor
developmental progress
 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subj.Data: Constipation related to Within 30 minutes of Independent: After 30 minutes of

nutritional imbalance nursing intervention, the nursing intervention.
“Bihira siyang dumumi patient’s S/O will >Encouraged to drink The patient’s S/O
eh. Di kasi mahilig verbalize the appropriate plenty of fluids verbalized the
kumain ng mga pagkain interventions for the appropriate interventions
na nakakapagpadali ng Raitonale: Fluids soften
child’s constipation. the stool for the child
pagdumi.” As constipation, as
verbalized by the >Emphasized the evidenced by:
patient’s S/O. importance of eating
high fiber diet in the >S/O verbalizes
Obj. Data:
form of fruits such as “Sige, papakainin ko
> Dullness of the Papaya, pineapple, siya ng mga yun.”
abdomen cereals, etc.
>the S/O encouraged the
> Straining upon Raionale: High-fiber patient to drink plenty of
defecation diet promotes better water.
defectaion
> Bowel movement >Patient does ROM
ranges from zero to one >Advised exercises within his
per day activity/exercise within ability.
limits of individual
ability.

Rationale: To stimulate
contractions of the
intestines
Dependent:

> Administer
laxatives/suppositories if
prescribed by the
physician

Rationale: Laxatives
relieves constipation and
releases the stools

IDENTIFIED NURSING PROBLEMS
Acute pain r/t inflammatory process
Impaired physical mobility related to pain/
discomfort level 0
JUSTIFICATION
CUES JUSTIFICATION
>Pain scale of 7/10 Life Threatening
>Facial grimace
>Malaise Pain is our highest priority for the reason
>Restlessness that:
>Irritable
>Sleep disturbance Pain is an unpleasant sensory and
emotional experience arising from actual
or potential tissue damage or described in
terms of such damage. Facial grimace,
malaise, restlessness, irritability are signs
of discomforts brought by pain and may
indicate other signs and symptoms. Sleep
disturbances may reduce resting periods
which may affect fast recovery
> Limited range of motion Health Threatening
> Limited ability to perform gross motor Impaired physical mobility related to pain
skills is health threatening because limited
capabilities will lead to poor body

Constipation related to nutritional
imbalance
> Postural instability
> Discomfort when movement
> Dullness of the abdomen
> Straining upon defecation
> Bowel movement ranges from zero to
one per day
movement. There is discomfort which is
associated with difficulty in moving. And
because that there is physical immobility,
the patient will be having difficulty
supporting and maintain stability.
Health Threatening
Constipation related to nutritional
imbalance is health threatening because
there is a decrease in normal frequency of
defecation accompanied by difficult or
incomplete passage of stool. It happens
when there is nutritional imbalance
because there is less intake of fiber which
regulates and aids digestion, together with
fluids.