Assessment Subjective: Nasakit no umisbo nak tapos bassibassit ti rumwar nga isbok, ading. verbalized by the patient.

Objective: >Facial grimace. >Restlessness. >V/S taken as follows: T: 37.0 P: 84 R: 22 BP: 130/80

Diagnosis Acute pain related to diffuculty in urination as evidenced by facial grimace

Planning After the shift of nursing interventions, the patient pain will be controlled.

Intervention Independent: > Assess pain, noting location, intensity (scale of 0 10), duration.

Rationale >Provides information to aid in determining choice or effectiveness of interventions.

Evaluation

After 7 days of nursing intervention s, the patient pain will be relieved or controlled.

> Investigate report of bladder fullness.

>Urinary retention may develop, causing tissue distention ( bladder or kidney), and potentiates risk for further infection.

>Observe for changes in mental status,

>Accumulation ofuremic waste and electrolyte

behavior or level of consciousness. >Provide comfort measure like back rub, helping patient assume position of comfort. Suggest use of relaxation technique and deep breathing exercise. >Encourage use of sitz baths, warm soaks to the perineum.

imbalances may be toxic to the CNS.

>Promotes relaxation, refocuses attention, and may enhance coping abilities

>Promotes muscle relaxation

Assessment Subjective Nagatel atoy imak, sakak ken atoy rupak ading. Objective V/S T: 37.0 P: 84 R: 22 BP: 130/80 pigmented skin

Diagnosis Impaired skin integrity related to traction application as evidenced by pigmented skin

Planning After the shift of continuous nursing interventions, the patient will manifest outcome of improvement in the skin and oral tissue healing.

Intervention Independent Vital signs monitored and recorded. Demonstrated proper wound care.

Rationale Serves as baseline data Cleaning the wound will minimize the risk for infection and further swelling. This controls swelling and pain. It also promotes venous return.

Evaluation After the shift of continuous nursing interventions,the patient has an improvement in her skin and ti .

Advised the mother to elevate affected lower extremity from time to time.

ASSESSMENT SUBJECTIVE:

DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Ineffective breathing pattern related to acute marigatan nak nga infection and umanges, ken no decreased lung dadduma ket toy pay capacity as evidenced ngiwat ko ti panganges by marigatan nak nga ko umanges as verbalezed by the patient. Progressive fatigue Loss of appetite

After 8 hours of nursing intervention the patient will promote good respiratory function and treat infection and also promote comfort.

Monitor respiratory status, including vital signs, breath sounds, and skin color. Administer oxygen therapy as ordered.

Respiratory status assessment helps gauge the patients severity and whether its progressing. To provide relief from symptoms of hypoxemia and hypoxia. ABG levels and continuous pulse oximetry measures the bloods oxygen content and are good indicators of the lungs ability to oxygenate the blood. To increase chest expansion and to alleviate dyspnea.

After 8 hours of nursing intervention the patient was able to state comfort and improved breathing pattern

OBJECTIVE: V/S T: 37.0 P: 84 R: 22 BP: 130/80 productive cough . Crackles Dyspnea

Monitor ABG levels and oxygen saturation as ordered.

Place the patient in semi-fowlers position and place the diaphragm in proper position to contract.

Collect sputum samples as ordered.

To monitor the progress of the disease and treatment.