Date

A P R I L 25, 2 0 1 2

Cues Subjective cues: medyo sakit akong braso nga tuo, ug usahay ga ngutngotas verbalized by the patient Objective cues: >Pain scale of 6/10; moderate pain. >Grimaced face noted >Limited range of motion

Need

C O G N I I V E P E R C E P T U A L P A T T E R N

Nursing Diagnosis Acute pain related to tissue trauma Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. Source: Doenges, Geissler-Murr, Moorhouse (2004). Nurses Pocket Guide Ninth Edition. ,EA Davis Company.

Objectives After 8 hours of nursing care the client will verbalize a decrease of pain.

Nursing Interventions 1. Established rapport. To gain pts trust and cooperation. 2. Assessed patients vital signs every hour. To establish baseline data 3. Administer analgesic as ordered. To provide pharmaceutical treatment to alleviate pain. 4. Evaluate pain regularly (e.g., every 2 hr x 12) noting characteristic, location, and intensity.Provides information about need for/effectiveness of interventions. 5. Reposition as indicated, e.g., semi-Fowlers, lateral Sims. May relieve pain and enhance circulation. Semi-Fowler;s position relieves abdominal muscle tension and arthritic back muscle tension, whereas lateral Sims relieves dorsal pressures. 6.Encourage use of relaxation techniques, e.g., deep-breathing exercises, guided imagery, visualization, music.

Evaluation Goal met: After 8 hours, patient verbalized a decrease of pain by saying dli na kayo sakit pareho ganina. With pain scale of 3/10 which is mild pain.

relieves muscle and emotional tension; enhances senseof control and may improce coping abilities. 7.Provide diversional activities such as allowing the client read magazines or listen to music.By diverting the client attention to something interesting or pleasurable, this will take her mind off the pain. 8. Provided comfort measures such as positioning the client and tacking in the linens. To make client feel comfortable and promote relaxation. 9. Provided adequate rest and sleep and a safe environment. To save energyexpenditures, thereby decreasing body temperature &to reduce metabolic demands / oxygen consumption 10. Administered antibiotic as indicated. To treat underlying cause.

Date

Cues Subjective cues: wala kayo koy kusog kay medyo sakit akong lawas pagbalik naku diri sa ward. as verbalized by the patient

Need

Diagnosis Activity Intolerance related to pain secondary to post surgical procedure Inability to move purposely within the physical environment, imposed restrictions; limited ROM; decrease muscle strength/control discomfort on movements

Planning Within 8 hours span of nursing care, the patient will be able to Demonstrat e activity tolerance as evidenced by walking and doing ADL without assistance.

Nursing Interventions 1.Monitor vital signs To provide baseline comparison 2.Determine cause of activity intolerance Determining the cause of a disease can help direct appropriate interventions 3.Teach client the need to pace activity and rest after meals Rest periods decrease oxygen consumption. 4.Observe for pain before activity and, if possible treat pain before activity Pain restricts the client from achieving a maximum activity level and is often exacerbated by movement 5.Encourage to change position from supine to sitting several times daily and to avoid prolonged bed rest Immobilization and enforced bed rest in the supine position have considerable adverse effects on nearly every system in the body 6.Perform passive range-ofmotion exercise if client is unable to tolerate activity Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors

Evaluation GOAL MET. Within 8 hours span of nursing care, the patient was able to: >demonstrat e activity tolerance and identified techniques to enhance activity intolerance.

A P R I L 27, 2 0 1 2

Objective cues: >Grimaced face noted when moving >Irritable >Decrease mobility >Drowsy >Body malaise/ Weakness >Needs assistance in doing ADL

A C T I V I T Y E X E R C I S E P A T T E R N

contribute to contracture and limitation of motion 7.Implement measures to conserve the clients energy during activity Measures to conserve the clients energy enable the client to increase activity tolerance 8.Suggest that the client perform activities more slowly and for shorter time periods, resting more often, and using more assistance as required To promote optimal performance and achievement levels. Appropriate assistance ensure safety and prevents falling 9.Instruct client in energyconserving techniques, (e.g. sitting to brush teeth or comb hair, carrying out activities at as lower pace) Energy-saving techniques reduce the energy expenditure, thereby assisting in equalization of oxygen supply and demand. 10.Encourage progressive activity/ self-care when tolerated. Provide assistance as needed Gradual activity progression prevents a sudden increase in cardiac workload. Providing assistance only as needed encourages independence in performing activities.