ASSESSMENT

Subjective:
Madanagan nak nga

NSG. DIAGNOSIS
Anxiety related to
change in physical

maoperaan.As verbalized by

integrity as evidenced

the pt.

by verbalization

Objective:
Poor eye contact
Restless
Facial tension

Pre Operation

PLANNING
Within 2 hours of
rendering
intervention, patient
will identify ways to
deal with anxiety

INTERVENTION
Monitored and
recorded v/s

RATIONALE
Serve as baseline data
Reduces anxiety

Promoted expression
of feelings and fears
Reduces anxiety
Explained procedures
Encouraged family
member to treat client
as before

Reassure client that

has a role in the
family has not been
altered

EVALUATION
After 2 hours of
rendering effective
nursing intervention,
the client expressed
her feelings and
participate in her
health car.

Pre - Operation
ASSESSMENT
Nalaing nakon agawid
nakonAs verbalized by the
pt.
Appeared strong
Normal V/S
C good appetite

NSG. DIAGNOSIS

PLANNING

Wellness r/t effective

therapeutic regimen as
evidenced by strong in
appearance normal v/s and c
good appetite

Within the shift of rendering

nsg interventions, the pt
maintain normal body
functions

NSG. INTERVENTION
NPI established

to gain fruits

v/s monitored and

recorded

to serve as base line

data

advised to have
enough rest

to reduce fatique

advised for follow

up check up
advised to eat
nutritious foods

Post Operation

RATIONALE

to serve as basis for

continuity of care
to maximize energy
production

EVALUATION
With the S of rendering
effective Nsg interventions,
the pt maintained normal
body functions.

ASSESSMENT
S > haan ko maigaraw unay
toy sakak As verbalized by
the pt.
O> irritable
noted with limited
movement

NSG. DIAGNOSIS
Activity intolerance r/t
fracture as manifested by
irritability, noted c limited
movement

PLANNING
Within the shift of rendering
Nsg. Interventions, the pt.
will be able to participate
willingly & desired activities

NSG. INTERVENTION
NPI established

RATIONALE
to gain trust

v/s monitored
provided calm
environment
advised to have
adequate rest
encouraged active
ROME
assisted c ADLs

to serve as baseline
data
to reduce fatique and
promote relaxation
to reduce fatique
to maintain muscle
strength
to conserve energy &
promote safety

EVALUATION
Within the shift of rendering
effective Nsg.
Implementations, the pt. was
able to participate willingly
in desired activities.

ASSESSMENT
S> Haan nak pay ket
makapagnan As verbalized
by the pt.
O> Teary eyes
worried face

NSG. DIAGNOSIS

PLANNING

Impared walking r/t to neuro

muscular skeletal
impairement as manifested
by teary eyes and worried
face

Within the shift of rendering

Nsg interventions, the pt. will
be able to move about within
environment as needed

NSG. INTERVENTION

RATIONALE

NPI established

to gain trust

v/s monitored and

recorded

to serve as baseline
data

assisted pt. to do
ROME

to promote
circulation

advised to have
adequate rest

to reduce fatique

encouraged to eat
nutritious foods

to maximize energy
production

assisted c ADLs

to ensured safety

EVALUATION
Within the shift of rendering
effective Nsg.
Implementations, the pt. was
able to move about c in
environment as needed.

Post Operation
ASSESSMENT
S: nasakit toy sakak no
magaraw As verbalized by
the pt.
O: Limited ROM slowed
movement

NSG. DIAGNOSIS
Impaired physical mobility
r/t surgical pain secondary to
post surgical operation as
manifested by limited ROM

PLANNING
At the end of the shift, the
patient will be able to
demonstrate,
techniques/behaviors
resumption of activities

INTERVENTION

RATIONALE

V/S monitored

For baseline data

Assisted in
repositioning of the
patient

To maintain position
of function

Encouraged pts. To
do movement within
the limit of his ability

To promote optimum
level of function

irritability
V/S
BP 120/80 mmhg
PR 87 bpm
RR 21 cpm
To 36.2 OC

EVALUATION
At the end of the shift, the
patient demonstrated
techniques/behaviors that
enable resumption of
activities.