ASSESS DIAGNO EXPECT PLANNI RATION IMPLEM EVALUA
MENT SIS ED NG ALE ENTATIO TION
OUTCO N
ME
Subjective Chronic Patient *Assess *Obtain *Assess
Patient
data : pain demonstrat the general baseline pain scale
demonstrat
patient related to es condition data of the as 8/10.
ed
says that “I metastatic decrease in of the patient. decrease in
Have growth of pain. patient . pain as
pain .” cervix as evidenced
evidenced *provide *Enhance *Provided by
Objective by pain comfort comfort to air bed. decreased
data: scale devices to the patient. crying ,gua
*facial reading. the rding and
expression patient . pain scale.
*crying
*person *Provide *Enhance *Provided
guarding comfortabl comfort to sims
*pain scale e position the patient. lateral
reading. to the position.
patient .
*provide *Alter the *Assissted
diversonal concentrati in guided
activities. on of the imagery.
patient.
*Administ *Treat *administe
er pain underlying red
relieving cause. fentanyl
medication patches
s to the and
patient. injection
morphine.
ASSESS DIAGNO EXPECT INTERVE RATION IMPLEM EVALUA
MENT SIS ED NTION ALE ENTATIO TION
OUTCO N
ME
Subjective Impaired Client *Assess *Obtain *Assess
Client
data : physical exhibits the general baseline the general
exhibitsed
Patient mobility imoproved condition data of the condition
improved
says that “Irelated to physical of the patient. of themobility as
cannot metastatic mobility patient. patient.
evidenced
walk” growth of by steady
cervices as *Assist in *Encourag *Assisted gait and
Objective evidenced physiother e activity. in normal
data: by appy. physiother posture.
*unsteady waddling apy.
gait gait *Provided *Promote *Provided
*waddling walking walking. crutches.
gait devices to
*postural the patient.
abnormalit
y *Encourge *Enhance *Encourag
*difficulty in comfort to ed in ROM
in walking exercises. the patient. Exearcises
*provide *Enhance *provided
comfortabl comfort to knee cap.
e devices the patient.
to the
patient.
ASSESS DIAGNO EXPECT INTERVE RATION IMPLEM EVALUA
MENT SIS ED NTION ALE ENTATIO TION
OUTCO N
ME
Subjective Activity Client gets *Assess *Obtain *Assessed
Client got
data: Intolerance relief in the general baseline the general
relief from
Patient related to performing condition data of the condition
activity
says that ‘I fatigue as activities. of the patient. of the
intolerance
need evidenced patient, patient.
as
assistance by patient evidenced
for doing asking for *Provide *Encourag *Provided by
anything” help assisstance e in assistance decreased
of needs. activity. in walking fatigue.
Objective
data: *Encourag *encourag *Encourag
*Assisting e in mild e in ed in ROM
for help exercises. activity. exercises.
*fatigue
*Dizziness *Assist in *Promote *Assissted
physiother movement. physiother
appy. appy
ASSESS DIAGNO EXPECT PLANNI RATION IMPLEM EVALUA
MENT SIS ED NG ALE ENTATIO TION
OUTCO N
ME
Subjective Imbalance Client *Assess *Obtain *Assessed Client
data : d nutrition exhibits the general baseline nutritional exhibited
Patient less than improved condition data status of improved
says that “I
body nutritional of the the patient nutritional
don’t feel requireme status. patient. status as
like eating.
nts due to evidenced
lack of *Obtain *Improve *Obtain by
0bjective appetite as diet chart dietary diet chart increased
data: evidenced review changes review Hb and
*Pale by pale RBC
conjunctiv conjunctiv *Include *Improve
*Include Count.
a a nutritious health oranges,le
*Decrease food mons,ragi
d and
haemoglob *Provide *Increased spinach
in and menu plan blood
RBC count *No
Count *Provide *Increase dietary
*Lack of dietary heamoglob supplemen
appetite. supplemen in level ts were
ts as given
needed.
ASSESSME DIAGN EXPECT PLANNIN RATION IMPLEME EVALUA
NT OSIS ED G ALE NTATION TION
OUTCO
ME
Subjective Fluid Client *Assess the *Obtain Assess the Client
data: volume exhibits general baseline general ehibited
Patient says deficit improved condition data fluid improved
that “I Feel related to hydration of the volume hydration
dehydrated” decreased status patient status status as
thirst as evidenced
Objective evidence *Monitor *Understa *Monitored by normal
data: d by dry intake and nd the intake skin turgor
*Decreased skin output amount of output chart and
skin turgor chart fluid moisture.
*Dry skin intake and
*provide output
fluid
supplement *Improve *Administe
s hydration red normal
saline
*Monitor *Understa
urine nd fluid *Monitored
output output urine output
ASSESS DIAGNO EXPECT INTERVE RATION IMPLEM EVALUA
MENT SIS ED NTION ALE ENTATIO TION
OUTCO N
ME
Subjective urinary Client Assess the Obtain Assessed Client
data: retention exhibits general baseline the urineexhibited
related to improved condition data output. improved
Patient tumor urine of the urine
says that “i compressi output. patient. output as
have on as evidenced
decreased evidenced Catheterise decrease Catheterise by
urine by the bladder the urinary d the improved
output” decreased retention bladder urine
urine using output,
Objective output foleys pale
data: catheter. coloured
decreased urine,
urine decrease decrease decreased decreased
output fluid urinary fluid pain
yellow intake retention intake as during
coloured 1L urination
urine monitor monitor monitored
painful intake the amount 24hr urine
urination output of urine output
chart produced
administer treat no drugs
medication underlying were
s conditions administer
ed to my
client
ASSESS DIAGN EXPEC INTERV RATION IMPLE EVALU
MENT OSIS TED ENTION ALE MENTA ATION
OUTCO TION
ME
Subjective Disturbed Client Assess the Obtain Assesed Client
data: sleep exhibits general baseline the sleep exhibited
patient pattern improved condition data score of improved
says that “ related to sleep of the the patientsleep
i haven’t restlessnes pattern patient as 3/10 pattern
slept last s as asevidence
night” evidenced provide a enhance provided a d by
by calm and sleep sound decreased
objective drooping quiet comfort proof and drooping
data of eyelids environm a dark of eyelids,
ment environm decreased
drooping ment drowsiness
of eyelids provide enhance provided less
comfort sleep pillows, frequent
drowsines devices satiety trochanter yawning
s rolls. and
frequent provide a increase Provided decreased
yawning sufficient the lukewarm day time
increased protein duration of milk. sleepiness
day time rich diet sleep
sleepiness
administer treat No
sedatives if underlying sedatives
needed. conditions were given
to my
client
ASSESS DIAGN EXPEC INTERV RATION IMPLE EVALU
MENT OSIS TED ENTION ALE MENTA ATION
OUTCO TION
MES
Subjective Self care Patient Asesss Obtain Assessed Patient
data: deficit exhibits the general baseline the general exhibited
related to improved condition data condition improved
Patient fatigue as self care. of the self care as
says that “i evidenced client. evidenced
can’t even by asking by
do my self for help. Provide increase provided decreased
care help in activities help in help
activities” performing performed combing request,
activities. hair and increased
objective grooming hygiene
data: and
Assist in increase assisted in improved
asking for bathing hygiene bathing grooming
help
decreased
hygiene
lack of Provide encourage provided
grooming assistive in self care walking
devices activities sticks and
if needed crutches
