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Assessment Subjective: Nabaranakas verbalized by the patient Objective: -Pr:91bpm -Temp. 37.

9 -skin is warm to touch -flushing of skin

Diagnosis Hyperthermia r/t exposure to warm environment

Planning After 30 minutes of nursing intervention the patient will be able to maintain normal body temperature within (36.5-37.5)

Intervention Rationale -Performed tepid sponge -To decrease body bath temperature by means of evaporation and conduction -Encouraged wearing loose cotton clothing -To promote surface cooling

Evaluation -Goal met the patient was able to maintained normal body temperature of 36.8

-Encouraged patient to maintain oral fluid intake

-To support circulating volume and tissue perfusion -To reduce metabolic and oxygen consumption -To decrease fever by inhibiting the effects of pyrogen on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation

-Maintained on bed rest

-Administered paracetamol 500mg/tab per orem

Assessment Subjective: madinak pay nagdigusmanipud di nahospitalakas verbalized by the patient Objective: -poor hygiene -easy fatigability

Diagnosis Self care deficit r/t decrease muscle strength and endurance

Planning After 2 hours of nursing interventions the patient will be able to perform self care activities within level of own ability

Intervention -Assessed ability in performing activity of daily living -Encouraged patient to do self care independently or with minimal assistance such as combing her hair,and wiping herface,but provide assistance as necessary -Maintained a supportive,firm attitude and allow patient sufficient time to accomplish task

Rationale -Aids in planning for meeting individual needs -To maintain selfesteem and to promote comfort

Evaluation -Goal partially met the patient was not able to take a bath but she combed and wiped her face

-to show empathy and to know that careproviders will be consistent in their assistance -To enhance sense of self-worth and promotes independence

-Provided positive feedback for efforts and accomplishments

Assessment Subjective: Marigatanna kngaaggaraw as verbalized by the patient Objective: -Limited ROM -Difficulty turning and sitting -Easy fatigability

Diagnosis Impaired physical mobility r/t body weakness

Planning After 1 hour of nursing intervention the patient will be able to participate in activities such as turning and sitting with assistance

Intervention -Observed movement when client is unaware of monitoring -Encouraged adequate intake of fluid and nutritious food such as green leafy vegetables,fruits,and meats -Encouraged participation in the activity such as turning and sitting

Rationale -To note incongruencies with report of abilities

Evaluation Goal met,the patient was able to do turning and sitting position but with assistance

-To promote wellbeing and and maximize energy production

-To enhance selfconcept and sense of independence -To prevent pressure ulcers -To promote circulation

-Placed pillows on the bony areas like heels and elbows -Positioned patient on side and sitting position with time interval

Asssessment Subjective: Han nakmakapan gpanganunay Objective: -Decrease eagerness to eat

Diagnosis Imbalanced nutrition:Less than body requirements

Planning After 15 minutes of nursing intervention the patient will be able to demonstrate lifestyle changes to regain and/or maintain appropriate weight

Intervention -Assessed weight

Rationale -To establish baseline parameter

-Determined clients ability -Can affect ingestion and to chew,swallow and taste digestion of nutrients food -To stimulate appetite -Encouraged patient to choose foods within prescribed diet -To reduce possibility of early satiety -Promoted adequate or timely fluid intake and limit fluids 1hour prior to meal -To measure effectiveness of effort -Encouraged to weigh regularly

Evaluation -Goal met,the patient can demonstrate lifestyle changes to regain and/or maintain appropriate weight

Assessment Subjective: Nasakitatoyulokas verbalized by the patient -pain scale of 5/1o 0-3=less pain 4-7=moderate pain 8-10=severe pain Objective: -facial grimace -restlessnes

Diagnosis Acute pain related to Headache

Planning After 1hour of nursing intervention the patient will verbalize a decrease in pain from 5/10 to 1/10

Intervention -Assessed level of pain from pain scale 0/1010/10

Rationale -To determine nursing care to be given to patient

Evaluation -Goal met,the patient verbalized a relieve from headache from pain scale 5/10 to 1/10

-Encouraged deep breathing exercise

-To promote comfort and relaxation

-Encouraged patient to have enough rest

-To add comfort to patient

-Administer osmotic diuretic(Mannitol)as prescribed

-To help relieve pain

Assessment Subjective: Naminsannakpalang a tummakkimanipud di nahospitalakas verbalized by the patient Objective: -Restlessness

Diagnosis Constipation r/t Recent environmental changes

Planning After 2-3 hours of nursing intervention the patient will be able to verbalize return normal pattern of bowel functioning

Intervention -Assessed oral/dental health

Rationale -It may impede dietary intake

Evaluation -Goal unmet,the patient verbalized return of normal pattern of bowel functioning

-Determined oral fluid intake

-To evaluate clients hydration status

-Encouraged adequate fluid intake

-To promote passage of soft stool

-Encouraged a diet of balance fiber like papaya and pineapple

-To improve consistency of stool

-Administered Lactulose as ordered

-To relieve from constipation

Assessment Subjective: Naglakanak a mabannogas verbalized by the patient Objective: -Pale -Easy fatigability -Cannot stand alone -Shafling gait when walking

Diagnosis Activity intolerance r/t Generalized body weakness

Planning After 30 minutes of nursing intervention the patient will identify techniques to enhance activity tolerance

Intervention -Assessed emotional factors affecting the current situation

Rationale -Depression might be the result of being forced to inability

Evaluation -Goal met,the patient was able to identify techniques to enhance activity tolerance

-Encouraged intake of nutritious food like fruits,vegetables,and meats that are low salt and low fat -Encouraged appropriate safety measure like padding the side rails -Promoted comfort measures like deep breathing exercise -Planned care and balance rest periods with activities like flexion and extension of extrimities -Encouraged client to maintain positive attitude

-To improve health status and activity tolerance

-To prevent injuries

-To enhance ability to participate in activities

-To reduce fatigue and rechannel energy

-To enhance sense of

well being

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Nagsakitatoyayantibatokko as verbalized by the patient -pain scale of 6/10 Objective: BP:120/80 PR:94 -facial grimacing -Frequent touching of the nape -Irritability -Sweating

Acute pain related to compression of nerves secondary to prolonged lying on bed

After 1 hour of nursing intervention the patient will verbalize a decrease of pain from 6/10 to 2/10

-Assessed quality of pain

-To establish base line data

-Positioned comfortably on bed -Encouraged to do deep breathing and divertional activity like talking to significant other -Administered analgesic as ordered

-To alleviate pain

-Goal met,the patient verbalized decrease in pain from 6/10 to 2/10

-To divert attention from pain

-To relieve from pain

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Mabutengnak nu anyamapasamakkanyakgapu knatoysakitko.as verbalized by the patient Objective: -restlessness

Anxiety r/t possible medical outcome

After 1 hour of nursing intervention the patient will able to reduce anxiety

-Reviewed coping skills used in past

-To determine those that might be helpful in current circumstances -To avoid transmission of anxiety

-Goal met,the patient was able to reduce her anxiety as evidenced by relax appearance

-Established a therapeutic relationship ,conveying empathy and unconditional positive regard -Encouraged patient to do diversional activities like;listening to music and talking to significant other -Encouraged patient to express her feelings

-To relieve tension

-To promote relaxation

Assessment Subjective: Kasla lumteg atoy sakak, baka gapu ken adiyay kinnan ko a nalangsi, as verbalized by the patient Objective: -

Diagnosis Knowledge Deficit r/t unfamiliarity with information resources as evidenced by inaccurate perception with health perception

Planning After 30 minutes of nursing intervention the patient will verbalize understanding of disease process and treatment

Intervention -Assessed readiness and barriers to learning -Determined clients method of accessing information like visual and auditory -Encouraged patient to comply with the treatment regimen -Provided health teachings such as eating foods with low salt and fat,but avoid fishy foods

Rationale -It may impede learning To facilitate learning

Evaluation -Goal met,the patient understand disease process and treatment as evidenced by not eating fishy foods

-To fasten recovery

-To improve health status