Assessment Subjective data Sobrang sakit ng balakang ko.

Pain scale: 10/10 Objective data Guarding pain Facial grimace Irritability Self-focus restlessness

Diagnosis Altered comfort r/t inflammation of the bladder as manifested by guarding pain, irritability, facial grimace, self-focus and increased BP, PR, RR, temp. STG

Planning

Implementation Independent -Assess patients level of pain -Monitor VS. -accept clients description of pain. -Provide comfort measures (e.g., touch, repositioning, use of heat or cold packs, nurses presence), quiet environment and calm activities. -Instruct/ encourage use of relaxation techniques such as focused breathing. -Encourage adequate rest periods. Dependent -Administer analgesic, as ordered. -Administer IVF, as ordered.

Rationale

Evaluation

Within 30 mins of effective nsg intervention, the pain will decrease from 10/10 to 5/10. LTG After 2 to 3 days, the pain will be in a manageable manner and the patient will perform ADLs until discharge.

-for baseline data -for baseline data. -Pain is a subjective experience and cannot be felt by others. -To promote nonpharmacological pain management.

>After 30 mins of effective nursing intervention, the pain decreased from 10/10 to 6/10. The goal was partially met.

-To distract attention and reduce tension. -To prevent fatigue.

>After 2 days, the patient verbalized that the pain relieved and it is in a manageable manner. Goal met.

P-when moving Q- flunk pain R-lumbar area S-10/10 T-30 min to 1 hour BP: 160/90 PR: 110 RR: 28 Temp: 37.9 Lab results: Urinalysis 5-10 hpf (pus cell) RBC 1-5hpf

-To maintain acceptable level of pain.

-To promote adequate hydration.

Assessment Subjective data Mataas ang blood sugar ko Objective data Hgt = 504 mg/dL

Diagnosis Unstable blood glucose related to lack of adherence to Diabetes management and inadequate blood glucose monitoring as evidenced by Hgt of 504. STG

Planning

Implementation Independent

Rationale

Evaluation >After 30 mins of effective nursing intervention, the pain decreased from 10/10 to 6/10. The goal was partially met.

Within 15 30 minutes of nursing interventions the patient will verbalize plan for modifying factors to prevent/minimize shifts in glucose level LTG Within 5 days of nursing interventions the patient will maintain glucose in satisfactory range Less than 120 mg/dL

Assess blood sugar level Monitor VS. Provide information on balancing food intake, antidiabetic agents, and energy expenditure Review clients diet, especially carbohydrate intake Encourage client to read labels and choose foods described as having a low glycemic index (GI), higher fiber, and low fat content Provide diet 2400 calories 3 meals/2snacks

To monitor blood glucose level For baseline data. To gain adherence to therapy

Glucose balance is determined by the amount of carbohydrates consumed These foods produce a slower rise in blood glucose

>After 2 days, the patient verbalized that the pain relieved and it is in a manageable manner. Goal met.

Proper diet decreases glucose level/insulin needs, prevents hyperglycaemic episodes, can reduce serum cholesterol level

Instruct and encourage To promote weight loss the client to have regular excercise

Dependent Administer antidiabetic medication as ordered. (Humulin) Treats underlying metabolic dysfunction reducing hyperglycemia and promoting healing

Collaborative Schedule consultation with dietician to restructure meal plan and evaluate food choices Calories are unchanged on new orders but have been redistributed to 3 meals and 2 snacks

Assessment Subjective data Nahihirapan akong huminga

Diagnosis Ineffective airway clearance related to excessive mucus production as manifested by difficulty of breathing and cough

Planning STG Within 30 mins of effective nsg intervention, the secretion will be reduced

Implementation Independent -Monitor VS especially RR -evaluate cough and gag reflex and swallowing ability -position head appropriately -encourage deep breathing and cough exercises -encourage bed rest

Rationale

Evaluation

-for baseline data. - to determine ability to protect own airway -For lung expansion -To loosen secretions

>After 30 mins of effective nursing intervention, the secretion was reduced. The goal was met!

Objective data -use of accessory muscles -difficulty of breathing -cough -x ray result remarks pneumonia -crackles VS: RR: 25

-prevents and reduces fatigue

-To liquefy secretions -instruct client to have increase fluid intake -teach and provide CPT -stand by oxygen tank Dependent -Administer bronchodilator (ventolin) as ordered - to facilitate breathing - to loosen secretion - for emergency purposes

-to facilitate breathing

Collaborative -refer to the respiratory therapist

-to promote individual care