DIAGNOSIS: Chronic pain related to disease process as manifested by presence of mass on the leg.

ASSESSMENT PLANNING NSG. INTERVENTION RATIONALE EVALUATION

After 4 hours of Independent: After 4 hours of
Subjective: nursing intervention, -Monitored vital -Alterations to nursing intervention,
“ Madalas sumakit ng the client will signs until stable normal may the client had
bukol ko sa bandang increase his comfort, and checked be a sign of increased his comfort
tuhod” as verbalized and decrease pain. dressing. infection. and decreased pain.
by the patient. Moistened
dressings are
favorable site
for
Objective: microorganism
- + swelling to culture.
- Presence of
mass on the -Encouraged -To divert
leg minimal attention on
- V/S as follows: movement pain and
T- 37.4 of increases
P-82 unaffected circulation.
R-21 part.
BP- 140/80
-Adjusted -This is to
bandage if prevent
constricted Diminished
and advised circulatory &
to elevate nerve function
leg and to control
swelling of the
site.

-Instructed and -Help to

demonstrated promote
of how to do circulation,
a deep relaxation of
breathing muscles.
exercise.

Dependent:
-Administer pain -to reduce pain
reliever temporarily
DIAGNOSIS: Impaired physical mobility, inability to stand alone related tissue perfusion as manifested by swelling on
the leg

ASSESSMENT PLANNING NSG. INTERVENTION RATIONALE EVALUATION

Objective: After 4 hours of Independent After 4 hours of
- + swelling nursing interventions - assist patient to -to improve nursing interventions
- Presence of the patient will be do active ROM muscle the patient had
mass on the able to: exercises on the strength and able to:
leg 1. Demonstrate lower extremities. joint mobility. 1. Demonstrate
- V/S as follows: increasing increasing
T- 37.4 function of - consult with -to develop function of
P-82 the physical or individual the
R-21 extremities. occupational exercise or extremities.
BP- 140/80 therapist as mobility
2. Regain or indicated. program and 2. Regained or
 maintain identify maintained
mobility at appropriate mobility a little
the highest adjunctive
possible devices. 3. Verbalized
level. understanding
-assess degree of -assess degree of of the
3. Verbalize mobility produced mobility produced situation /risk
understanding by injury or by injury or factors,
of the treatment and note treatment and note individual
situation /risk patient’s patient’s therapeutic
factors, perception of perception of regimen and
individual immobility. immobility. safety
therapeutic measures.
regimen and Dependent
safety -administer -in order for
measures. analgesics such as the muscle to
Tramadol (Tramal) be more relax
as prescribed by and relieves
the physician. the pain

DIAGNOSIS: Risk for infection related to altered immune system as manifested by the swelling on the leg

ASSESSMENT PLANNING NSG. INTERVENTION RATIONALE EVALUATION

Objective: After 2 hours of Independent After 2 hours of
- + swelling nursing intervention nursing intervention
- Presence of the patient will gain 1.Teach patient to ➢Hand washing the patient had gain
mass on the knowledge in wash hands often, reduces the risks for knowledge in
leg infection control as especially before infection infection control as
- V/S as follows: evidenced by toileting, before evidenced by
T- 37.4 discussing the wound meals and before and discussing the wound
P-82 care. after administering care.
R-21 self-care
BP- 140/80 2.Discuss to patients ➢To impart to the
the following signs of patient when the
infection wound become
- redness, swelling, infected and when to
increased pain, or sought medical care
purulent drainage on
the site and fever
➢To know if the
3.Demonstrate and patient really
allow understand the
return demonstration principle of proper
of wound care wound care.