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-v/s (GULANICK
& MYERS:
• BP: 2007, p. 129)
130/80
mmHg
• T: -patient may
38.2°C be restricted
• P : 75 by self-view
bpm or self-
• R : 20 perception out
cpm Independent
of proportion
-assess degree of with actual
2. Regain or mobility produced physical
maintain by injury or limitations
mobility at treatment and note requiring
the highest patient’s interventions
possible perception of to promote
level. immobility. progress
toward
wellness.
(GULANICK
& MYERS:
2007, p. 127)
3. Verbalize
understanding
of the
situation /risk
factors,
individual
therapeutic
regimen and
safety
measures.
NURSING SCIENTIFIC BASIS GOAL & NURSING
OUTCOME ACTIONS &
CUES DIAGNOSIS CRITERIA NURSING RATIONALE EVALUATION
ORDERS
- Establish a
trusting
relationship
that
Independent encompasses
-establish a patient’s
specific time to physiological,
talk with patient emotional,
about pain and its social, sexual,
psychological and and financial
emotional effects. concerns.
(SPARKS &
TAYLOR,
2005: 227)
- Pain is a
subjective
experience
and cannot be
felt by others.
(DOENGES,
2002: 367)
- to achieve
Dependent pain
management
-accept client’s
goals and
description of maximize
pain. patient’s
3. The patient cooperation.
(SPARKS &
will appreciate
TAYLOR,
the care
2005: 227)
rendered.
Collaborative
-work closely
with staff and
patient’s family.
Subjective
cues:
-“lisod man
ilihok akong
lawas” as
verbalized by
the patient.