NAME: B.C.

C/C Abdominal pain and vomiting

gravidarum
Date and
Time
December
17, 2014
@ 9AM

AGE/SEX: 19/F
ATTENDING PHYSICIAN: Dr. E. Palabyab

Cues

Need

S: First time
man gud nako
mabuntis, unya
nakulbaan pud
ko kung unsay
buhaton labi na
karon kay naa
pud ko UTI. As
verbalized by
the client.

Self
perceptio
n self
concept
pattern.

O:
With CC of
abdominal pain
and vomiting
(+) URTI t/c UTI
G1P0; 12 wks.
AOG
(+) nausea and
excessive
vomiting.
With (+)
abdominal pain.

Nursing diagnosis
Anxiety r/t lack of
knowledge of
pregnancy and
effects of disease in
the baby.

Objective of care
Within our 6 hours
span of care the
patient will manage
anxiety with positive
coping mechanisms
as evidenced by:
a. Vital signs
maintained at
normal level.
b. Anxiety scale
of 1 from
scale of 0- 5
where 5 is
the highest.
c. Absence of
facial tension
and improved
attention
span.
d. Expresses
confidence in
herself, her
support
person, and
the
healthcare

ROOM NUMBER: 307-1

DIAGNOSIS: G1P0, hyperemesis
Nursing intervention
INDEPENDENT
1. Establish rapport
and good working
relationship with
the client.
R: To gain the clients trust
and cooperation.
2. Monitor vital signs
R: To obtain baseline data
and to monitor possible
abnormalities.
3. Assess level of
anxiety through
verbal and nonverbal cues.
R: To identify areas of
concern and to be able to
know the proper nursing
care to be rendered.
4. Employ a calm,
caring, confident,
and nonjudgmental
approach to the

evaluation
December 17,
2014 @ 3PM
Goal met.
Within our 6 hours
span of care the
patient was able to
manage anxiety
with positive
coping
mechanisms as
manifested by:
a. Vital signs
maintained
at normal
level
T- 36.1*C
P- 90 bpm
C-92 bpm
R-20 bpm
BP- 100/60 mmHg
b. Anxiety
scale of 1/5.
c. The patient

With observed
fatigue,
weakness and
restlessness.
With observed
worried and
resentful facial
expressions.
With observed
disturbed
sleeping
pattern.
Facial tension
and facial
grimacing
observed.
VS:
T - 35.9*C
P -90 bpm
R 21 bpm
C 93 bpm
BP- 90/60
mmHg

personnel.
e. Verbalizes
relief from
anxiety.

client.
R: Enhances the nurseclient relationship.
5. Allow client to
express fears and
feelings of anxiety.
R: it provides a healthy
outlet of emotions and
relieves anxiety.
6. Acknowledge
normalcy of fear
and provide
opportunity for
questions and
answer questions
honestly within
clients level of
understanding.
R: adequate explanation
helps reduce anxiety,
soothe fears, and
provides assurance.
7. Provide diversions
(e.g. stress ball,
entertainment)
R: in order that the client
will not focus on the
anxiety he/she is feeling.
8. Offer support to the
client. (e.g. staying

is observed
to be
relaxed ,
comfortable
and is able
to rest and
sleep
appropriatel
ely.

d. Karon
kabalo nako
na
kaylangan
jud diay
magamping ug
naa man
pud si
mama na
kanunay
naa na
mutabang
nako. As
verbalized
by the
client.
e. Nawala na
akong
kabalaka
miss, at
least

with the client,

patting her arms
and brushing a
whisp of hair off her
forehead).
R: provides feeling or
sense of security and trust
between the nurse and
the patient.
DEPENDENT
9. Administer antianxiety
medications as
ordered by the
physician
R: the drugs mechanism
of action is to relieve
anxiety.
COLLABORATIVE
10. Refer to support
groups as needed.
R: provides ongoing and
timely support to the
client.

NAME: S.M.

AGE/SEX: 59/M

ROOM NUMBER: 308-4

nakabalo
nako kung
unsa akong
angay
buhaton.
Salamat
kayo. As
verbalized
by the
patient.

C/C: pain; R forearm due to VA

Date
and
Time
12/15/1
4
@ 9AM

Cues
S: sakit
kayo pag
matarog
akung
kamot. As
verbalized
by the
client.
O: with CC
of pain @
forearm d/t
VA
Fracture
on R
forearm
With
evident
facial
grimacing
With
guarding
behaviour
With
observed

Need

ATTENDING PHYSICIAN: DR. Batucan

Nursing diagnosis

Cognitive Acute pain r/t physical injury on R

forearm aeb facial mask of pain and
perceptu guarding behaviour.
al health
pattern
R: Injuries to our muscles, bones,

or internal organs can cause pain,

which may continue for weeks,
months, or even years.
Persona/physicall injury victims
can experience pain from jarring
of their neck or back, a broken or
sprained knee or ankle, head
trauma, lacerations, or any
number of other injuries.
R: Calisi, J. (n.d.). Pain and
Suffering Reimbursement for
Emotional Distress. Retrieved
January 4, 2015, from
http://www.injuryclaimcoach.com/p
ain-and-sufferingreimbursement.html

DIAGNOSIS: Fracture on R forearm

Objective of care

Nursing
intervention

That at the end

of 6 hours
nursing
interventions the
client will
alleviate pain
aeb:

1. Establish
rapport and
good
working
relationship
with the
client
R: to gain clients
trust and
cooperation

a. Clients
verbalizati
on of relief
from pain
b. Pain scale
of 1 from
1-10
where 10
is the
highest
c. Dimished
facial
grimacing
and
guarding
behaviour.
d. Promote

2. Assess
descriptive
characteristi
cs of pain
including
location,
quality and
intensity on
the scale of
1-10,
temporal
factors and
sources of
relief, pain
tolerance,
ethnicity,
attitude and
values.

evaluation
12/15/14 @ 3PM
Goal met.
At the end of 6
hours nursing
interventions the
client was able to
alleviate pain aeb:
a. nahuwasan
na akong
gibati. Dili na
kayo sakit
akong kamot
pag gunitan
o matarog.
As
verbalized by
the pt.
b. Pain scale of
1/10
c. Shows
relaxed and
comfortable
facial
expression.
d. Patient was

restlessne
ss and
discomfort
With
elastic
bandage
with splint
applied on
R forearm
Pin scale
of 5 from
0-10 where
10 is the
highest
With (+)
tenderness
upon
palpation
on affected
area
With VS of:
T- 36.1
C- 97
P- 95
R- 17
BP- 140/90

comfort
and rest.

R: descriptions
about particulars
of pain will help
determine what
goals are realistic
for the client.
3. Listen to
clients
description
of pain.
Allow time
for the
patient to
talkabout
his/her
frustration.
R: listening
attentively gives
the patient a
feeling that the
nurse is
interested. It also
helps determine
the progress in
alleviating pain.
4. Apply heat
or cold
compress
as
prescribed.
R: to minimize or
relieve pain.

able to sleep
and rest
appropriately.

5. Reposition
patient and
use pillows
to splint or
support
painful
areas as
appropriate.
R: to reduce
muscle spasm and
redistribute
pressure on body
parts.
6. Provide
patient with
sleep aids
such as
pillows,
bath before
sleep or
reading
materials.
Milk and
some highprotein
snacks
such as
cheese and
nuts,
contain Ltryptophan
and are

also sleep
promoters.
R: personal
hygiene and
prebedtime rituals
promote sleep in
patients. Comfort
measures act as
distracters from
pain , reduce
muscle
tension/spasm, &
redistribute
pressure on body
parts.
7. Encourage
adequate
rest
periods.
R: to avoid fatigue.
8. Encourage
diversional
activities
(eg.
TV/radio,
socializatio
n with
others.
R: to divert the
patients attention
in order for his/her
not to focus on the

pain felt.
9. Teach
patient
relaxation
techniques.
Such as
deep
breathing,
meditation,
aromathera
py, and
progressive
muscle
relaxation.
R: purposeful
relaxation efforts
usually promotes
sleep and comfort.
10. Administer
analgesic
medications
as
prescribed.
R: the drugs
mechanism of
action is to relief
pain.
R: Ralph, S. &
Taylor, C. (2011),
Sparks and
Taylors Nursing

Diagnosis Pocket
Guide. China.
Wolters Kluwer
Health / Lippincott
Williams and
Wilkins.
Doenges, M. Et.al
(2009), Nurses
Pocket Guide
Diagnoses,
Prioritized
Interventions and
rationales, ed. 11 .
Philadelphia, USA.
F.A. Davis
Company.

NAME: M.B.
C/C: fever
Date and
Time
01/20/15
@ 8AM

AGE/SEX:3 /M
ATTENDING PHYSICIAN: DR. Gallardo
Cues

Need

Snag-paadmit
mi kay dli
naman gud
mubaba iyang
kalintura
hangtod karon
init lang gihapon
sya. As
verbalized by

Nutritiona
l
metabolic
pattern

ROOM NUMBER: 244

DIAGNOSIS:

Nursing diagnosis
Hyperthermia

Objective of care
r/t

After 2 hours of

dehydration

aeb

nursing

flushed

and

intervention

skin

warm to touch skin

patient will
a.

R:if your body is

the

body

decrease

Nursing intervention

evaluation

1. Monitor

the 1/20/15 @ 10 am
Goal met
temperature of the
patient
Rationale:
monitor

to
if

temperature

the

the watcher.
O: with cc of
fever.
With IFV of
D5IMB 500 @
55 cc/hr.

severely dehydrated
you may experience
symptoms like fever

temperature

increases

from 38.1 to 37

decreases

degrees celcius

2. Provide

tepid

b. vital signs

sponge bath

will

Rationale:TSB

return

normal

to

range;

helps lowering the

With 1x episode
of vomiting

with a

Med. Of
paracetamol
250/5ml q4 prn
for fever

of 16-20 cycles

to

per minute.

flud intake

TSB for fever

or

respiratory rate

body temperature.
3. Instruct the patient
increase

Rationale:

oral
to

prevent
dehydration

Warm flushed
skin
Irritable

4. Instruct the patient

to

wear

light

clothes

Observed body
weakness

Rationale:

(+) loss of
appetite

and

VS:
T:38.4
CR-148
R-23

decrease

these
warmth
increase

evaporative cooling
5. Maintain

in

bed

rest
Rationale:

to

BP-80/60

reduce

the

metabolic demand
6. Rechecked

vital

signs after TSB

Rationale: to know
the effectiveness of
nursing
intervention
and

done

know

the

progress

of

patients condition
7. Administer
medication

as

ordered
Rationale:

to

reduce the fever

Date and
Time

Cues

Need

Nursing diagnosis

Objective of care

Nursing intervention

evaluation

Date and
Time

Cues

Need

Nursing diagnosis

Objective of care

Nursing intervention

evaluation