ASSESSMENT NURSING OUTCOME PLANNED INTERVENTION RATIONALE EVALUATION

DIAGNOSIS IDENTIFICATION
S: “MASAKIT PARIN Acute Pain r/t Present S.T.O :
UNG SINGAW KO KAYA Illness  After 24 hrs of nursing
DI AKO MAKAIN” as intervention the patient
verbalized will verbalized relief of
anxiety and body
O: weakness.
 After 24 hrs of nursing Tx:
 weak body intervention the patient
movement will demonstrate use of
 limited body relaxational activities
movement as indicated for
 irritable at times individual situation
 warm skin to L.T.O:
touch  After 3 days of nursing
 afebrile 36.0 intervention the patient
 occational will incorporate
productive cough therapeutic regimen
 with dressing into activities of daily
intact at the right living (ADL)
foot  After 3 days of nursing
interevntion the pt will
follow pharmacological
regimen as prescribed.
Dx:
 Assessed general health
status
 Monitored and recorded
v/s
 Established Rapport
 Ensured safety and
comfort measures
 Encouraged adequate rest
period
 Encouraged verbalization
of feelings and concerns
 Evaluated ability to
understand events,
provided realistic
appraisal.
 Encouraged client to use
affirmation “ I am healing,
I am relaxed”
S.T.O :
 To determine any
underlying
abnormalities
 To have a baseline data
 To gain cooperation
and trust with the pt.
 To help client achieve
OLOF
 To prevent fatigue
 To evaluate clients L.T.O:
status.
 To determine the clients
ability to recognize
present status.
 To help patient manage/
lessen pain
psychologically
 After 24 hrs of nursing
intervention the patient
will be able to
verbalized relief of
anxiety and body
weakness.
 After 24 hrs of nursing
intervention the patient
will be able to
demonstrate use of
relaxational activities as
indicated for individual
situation
 After 3 days of nursing
intervention the patient
will be able to
incorporate therapeutic
regimen into activities of
daily living (ADL)
 After 3 days of nursing
interevntion the pt will be
able to follow
pharmacological regimen
as prescribed.