ASSESSSMENT NURSING PLAN GOAL NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Acute Pain After 8 hours of shift,  Perform  To know the Goal Met: After 8 hours of
 “Masakit ang related to patient will exhibit comprehensive severity and shift, patient was able to
ulo at batok physical wellness, as evidence assessment of cause of the exhibit wellness as evidenced
ko.”AVB the discomfort by: pain. pain by:
patient. secondary to  Rated pain as  Determine  Able to rate pain as
 Rated pain HPN. 3/10 from possible causes 3/10 from 6/10, 10
as 6/10, 10 6/10, 10 being of pain. being the highest.
being the the highest.  Absence of facial
highest.  Absence of  Assess client’s  To know how to grimace.
facial grimace perception of deal and what  Absence of guarding
OBJECTIVE:  Absence of pain noting to give the behavior.
 With facial guarding attitude towards patient for the  Verbalization of feeling
grimace. behavior. pain and use of pain felt. of relief.
 With  Verbalization specific pain  No longer restless
guarding of feeling of relievers.  No longer irritable
behavior. relief.  Able to communicate
 Restless  No longer  Note client’s  Individuals with well with good
 Irritable restless. control over external locus of attention.
 Seems to  No longer responsibility for control may
have less irritable. pain take or no
attention  Able to management. responsibility
span when communicate for pain
being asked. well with good management.
 Seems not attention.
attentive and  Perform pain  To rule out
cooperative. assessment each worsening/deve
time pain occurs. loping
complication.

 Accept client’s  Pain is

description of subjective
pain. experience and
cannot be felt
by others except
the person
himself.
 Observe non-  Observations
verbal cues may/may not be
congruent with
verbal reports
indicating need
for further
evaluation.

 Monitor v/s  To be able to

specifically BP monitor and
know
differences as
point of
comparisons.

 Provide comfort  To provide non-

measures pharmacological
pain
management.

 Instruct/encoura  To divert
ge relaxation attention and
exercise (deep promote
breathing relaxation.
exercise,
massage).

 Administer  To maintain
analgesic as acceptable level
indicate. of pain.
 ASSESSMENT NURSING PLAN GOAL NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIION
SUBJECTIVE: Noncompliance After 3 days of home  Discuss with  To be able to be GOAL MET: Patient was able
“ Minsan kasi to medication visit, patient will client their aware of to manifest/demonstrate
nakakalimutan ko intake related manifest/demonstrate perception/un patient’s progress in condition and
uminom ng gamot at to adherence progress in condition derstanding of perception on understood need for
kasi nga wala naman to the and understood need the situation. medication. compliancy as evidenced by:
akong nararamdaman medication for compliancy as  Patient is more
na dapat ako inom ng regimen. evidenced by:  Listen attentive and concern
gamot”, as verbalized by  Patient is more to/active-  Knowing and about health.
the patient. attentive and listen client’s accepting
concern about complaints, client’s  Reports on religious
OBJECTIVE: health. comments. perception and intake of medication
 Seems to be not  Reports on assessing and its importance.
attentive when religious intake client’s
taking of of medication knowledge on  No longer agitated
medication is and its his/her when asked about
reinforced. importance. acceptance of medication intake.
 Failure to take  No longer medication
medications or agitated when regimen.
maintenance on asked about
time/religiously. medication  Be aware of
 Seems agitated intake. developmenta  Sometimes
when asked l level as well chronoligical
about taking as age does not
medications. chronological coincide with
age of client. patient’s
perception or
knowledge.

 Assess
availabilities  To know and be
of support aware of
systems and patient’s
resources. support system.

 Develop  Promotes trust,

therapeutic provides
nurse-client atmosphere in
relationship. which
 client/Significan
t other can
freely express
views/concerns.

 Review  Sets priorities

treatment and encourages
strategies. problem solving
Identify which areas of conflict.
interventions
in the plan of
care are most
important in
meeting
therapeutic
goals and
which are
least
amenable to
compliance.

 Contract with  Enhances

the client for commitment to
participation follow through.
in care.

 Encourage  To improve
client for self- abilities.
care,
providing for
assistance
when
necessary.
Accept client’s
evaluation of
own
strengths/limi
tations while
working with
client.
 Have client
paraphrase  Helps validate
instructions/in client’s
formation understanding
heard. and reveals
misconception.
 Reinforced
importance of  To attain
following progress and
medication health
regimen. developments.