ZAMORA, Maria Loreta B.

ASSESMENT DIAGNOSIS RATIONALE PLAN INTERVENTION RATIONALE EVALUATION

Goal:
S - “May Impaired skin There is reported • Assess the • Assessment is After the 30 minutes
natapakan integrity related to bleeding, pain and After 30 minutes client’s wound done in order to of nursing
akong laruan presence of itchiness around of nursing and record establish intervention the
ng bata sa wound the affected body intervention: gathered data. comparative client was able to
bahay, na-out part. baseline data of demonstrate:
of balance  The client’s client’s present
ako at Patient reports wound will be condition. • Absence of
tumumba. pain and itchiness free from injury. wound injury
Doon ako around the • Perform proper • Proper
nagkaroon ng affected area.  The sensation performance of • A lessened
wound cleaning
sugat. Hindi felt by client will wound cleansing sensation of pain
techniques
naman ito be lessened will prevent further felt
malilim at from 5/10 to at damage and
hindi rin least 3/10. infection. It also • Absence of
gaanong promotes wound itching around
masakit. Kung  Client’s healing. the affected area.
I-rarate ko sensation of
yung sakit. itchiness will be•
5/10 lamang Demonstrate to • Provide the client
lessened or will and his family
ito. Wala the client and
be completely members with the
naman akong family members
eradicated. knowledge of the
nararamdama how to perform
ng kakaiba proper wound benefits of proper
Objective: wound cleansing
bukod ditto at cleansing.
matagal na will stress it’s
 Teach client importance to
din noong huli how to do
akong nagpa- speedy wound
correct wound healing.
injection ng cleansing.
anti-tetano.”
• Apply dressing to• Wound dressing
O - There are the wounded will protect the
abrasions area. wound and the
found on the surrounding
client’s right tissues from
knee. It is 4cm foreign substances
in diameter and further injury.
and has
irregular
borders. It is
red in color
due to a small
presence of
blood. The
surrounding
area shows
sings of
minimal
swelling and is
reddish in
color. There
are small
N2-C
NURSING CARE PLAN: WOUND
ZAMORA, Maria Loreta B.
N2-C

NURSING CARE PLAN: FEVER

ASSESMENT DIAGNOSIS RATIONALE PLAN INTERVENTION RATIONALE EVALUATION

Goal:
S – “Kagabi Hyperthermia The body • Monitor patient’s • Assessment is After a 3 hour
suamasakit ng sobra related to temperature is After a 3 hour vital signs done in order to nursing
yung sugat ko, parang infection. controlled by the nursing intervention: establish intervention:
tumitibok ung parte ng hypothalamus, a comparative
katawan ko na section of the brain  The client’s baseline data of  The client’s
malapit that acts just like temperature will client’s present temperature
sa sugat ko. your household drop from 39.0°C condition. was reduced to
Naramdaman ko na thermostat. That is, to a normal range normal range
lang bigla mainit yung if the body gets too  The client will • Provide a tepid • Sponge baths  The client, as
pakiramdam ko.” cold, the thermostat show signs of verbalized, is
sponge bath increase heat
sends out comfort, reduced comfortable
loss through
O - The client had instructions to warm manifestations of and is no
conduction
warm to touch flushed things up, and if it restlessness longer restless
skin, excessive gets too hot, the
sweating. thermostat tries to • Reduce physical • Reduction of
Objective:  The client
cool things down. activity physical activity
manifested
Restlessness, body When the body is will limit heat
 The patient will signs of normal
malaise faced with an production
be able to thermoregulator
infection, it responds demonstrate y behaviors.
Upon assessment, in a number of ways. normal • Apply ice bag • To provide them
the client’s vital thermoregulation covered with a with adequate
signs were as behavior towel to the knowledge on
follows: groin how to clean
 Temp: 39.0 °C and dress
 PR: 80 beats/min wound to
 RR: 18 prevent further
breaths/min infection of the
 BP: 110/70 mmHG wound.

• Weigh the client • It is an indicator

regularly of overall fluid
and nutritional
status.
ZAMORA, Maria Loreta B.
N2-C

NURSING CARE PLAN: SPRAIN

ASSESMENT DIAGNOSIS RATIONALE PLAN INTERVENTION RATIONALE EVALUATION

Goal:
S – “Nagmamadali Impaired Physical Behavior such as • Assess the • To obtain After a 2 hour
akong bumaba ng Mobility related to limitation in After a 2 hour client’s condition baseline data intervention:
hagdan kanina. Sa inflammation of independent, intervention: and the PQRST for comparison
sobrang the ankle joint purposeful physical of pain felt. of the  The pain
pagmamadali ko, movement of the  Perform proper development of sensation felt
nagka-mali ako ng body or of one or comfort the injury. by the client
tapak at nalaglag more extremities measures the will • Apply cold was reduced
ako ng mga pitong indicating loss of ensure the compress for 15 • This will aid in
baitang. bone integrity was client’s relief from minutes or less the  Proper
Nakaramdam ako manifested pain. Pain only within the vasoconstrictio procedures
ng matinding sakit sensation felt by first 24 hours of n thus reducing were performed
sa may the client will be the occurrence blood flow and that will
paa ko pagkatapos. reduced from of injury only. reducing ushered the
Hindi na nawala ang 8/10 to 3/10 or inflammation client into a
sakit na iyon less. • Apply splint to speedy
hanggang ngayon.  Perform proper the sprained • Immobilization recovery
Noong sinubukang procedures that area and advice of the injured
kong tumayo ay will promote the client to rest. area will  The client was
hindi na ako faster sprain decrease the able to
nakatayo. Kung I- healing. risk for further demonstrate
rarate ako ang sakit, injury and will proper care of
8/10 ito.”  The client will be also prevent the injured joint.
able to fatigue
O - There is swelling demonstrate After 3 days of
• Apply hot and
and tenderness on proper care of the nursing
cold compress
the client’s left ankle injured joint. intervention:
alternately with • To aid in the
15-minute healing of
There is un equal Objective:  The client was
intervals. ligaments.
strength on both able to perform
sides of the body After 3 days of activities of
nursing intervention: • Advise to daily living with
Joint movement is minimal
not possible elevate affected
 The client will be extremity • This will control assistance and
able to perform was able to
 activities of daily swelling and show
living with • Educate the pain manifestations
minimal client and family of return of
assistance members on normal
 The client will how to reduce • This will reduce musculoskeleta
show pain pain and l activity.
manifestations of promote
return of normal independence
musculoskeletal on the client’s
activity. part