Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute Pain related Short term goals: Independent: Short term goals
“Masakit yung kaliwang to musculoskeletal At the end of 2 to 3 Perform an assessment of pain Indicates need for After 2 to 3 hours of
paa ko” as verbalized by impairment as hours of nursing to include location, effectiveness of interventions nursing interventions, the
the client evidenced by interventions, the characteristics, onset/duration, and may sign of development client was able to:
Pain Scale: 7/10 facial grimace, client will be able to: frequency, and severity. to the status of the client. • Take personal action to
restlessness, Take personal action Monitor vital signs (blood To evaluate client’s response control pain
Objective: guarding behavior, to control pain pressure, pulse, respiration). to pain • Verbalize method that
• Vital signs: irritability, and Verbalize method Instruct the client to do deep provide relief
o BP: 140/90mmhg Blood pressure of that provide relief breathing exercise To alleviate or control the • Demonstrate use of
• Facial Grimace 140/90mmhg, Demonstrate use of Encourage diversional pain relaxation skills and
• Restlessness relaxation skills and activities (E.g. TV/Radio, To divert and lessen the pain diversional activities
• Guarding behavior diversional activities socialization with others, felt by the client. Goal partially met
• Irritable listening to music)
Long term goal: Elevate and support the Promotes venous return,
At the end of 1 to 2 injured extremity using decreases edema, and may
days of nursing pillows or rolls. reduce pain. Long term goal:
interventions, the Create a calm and comfortable After 1 to 2 days of
client will be able to: environment. To promote proper rest nursing interventions, the
Report and client was be able to:
demonstrate a Report and
decrease in leg pain Dependent: demonstrate a
from 7/10 to 5/10. • Administer NSAIDs as decrease in leg pain
ordered by the Physician from 7/10 to 5/10.
Goal partially met
To maintain acceptable level
of pain
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Impaired physical Short term goal: Independent: • To determine client’s Short term goal:
“Nahihirapan akong mobility related At the end of 2 to 3 • Assess degree of mobility expectations/beliefs related to After 2 to 4 hours of
igalaw ang kaliwang binti to neuromuscular hours of nursing produced by injury or activity and potential long- nursing interventions, the
ko” as verbalized by the skeletal interventions, the treatment and note client’s term effect of current client was able to:
client impairment as client will be able to: perception of immobility. immobility. Also identifies verbalize understanding
Objective: evidenced by verbalize barriers that may be addressed of situation and
• Limited range of limited range of understanding of • Elevate and support the • To promote venous return, to individual treatment
motion motion, situation and injured extremity using minimize edema, and may regimen and safety
• Decreased muscle decreased muscle individual treatment pillows or rolls. reduce pain. measures
strength strength, and regimen and safety • Encourage participation on • Refocuses attention, enhances independently.
• Inability to move inability to move measures diversional or recreational client’s self-control and aids in Goal partially met
purposely purposely independently. activities like socialization reducing social isolation.
• Slow or having a small with others, listening to • To increases blood flow to
movement. music/radio muscle and bone; to improve Long term goals:
Long term goals: • Discuss and perform active or muscle tone, maintain joint After 2 days of nursing
At the end of 2 days of passive range of motion mobility; prevent contractures interventions, the client
nursing interventions, exercises of affected and or atrophy and calcium was able to:
the client will be able unaffected extremities. resorption from disease. increase strength and
to: • It will put too much strain in function of affected
increase strength joints joint
and function of • Advice the client to avoid • To prevent fall and injury perform ADLs and
affected joint heavy activity • To increase mobility and desired activity
perform ADLs and • Keep siderails up assist in ambulation Goal partially met
desired activity. • Encourage the use of assistive
device such as crutches or • To facilitate faster wound
walker. healing and bone healing
• Advice client to eat foods rich
in protein (fish, eggs), and
food rich in Vitamin C
