Cues Diagnosis Rationale Objectives Nursing interventions Rationale Evaluation

Subjective:
Accumulation of fluid
 “diri na ako Impaired physical causes the distention of  At the end of all Independent: >Identifies strengths  The family
nakakalakat hin mobility related to tissues so inflammatory interventions >Assess functional and deficiencies and members/caregivers
wray gamita nga paralysis. occurs, then stimulating the patient and ability and extent of may provide able to maintain or
tungkod ngan of pain receptors, family member impairment initially and information regarding increase strength
diri nakag lakat resulting to pain. will be able to on a regular basis. recovery. and function of
hin hirayo nga Patient limit know how to affected or
distansya ky movements, resulting maintain >Teach family members compensatory body
mag ul-ul ak tiil. to impaired physical strength, to change positions at >Reduces risk of tissue part,
mobility. function and least every 2 hours ischemia and injury. maintain optimal
Objective: skin integrity. (supine, side lying) Affected side has position of function
 Vital signs: and possibly more often poorer circulation and as evidenced by
BP- 130/70 if placed on affected reduced sensation and absence of
 Muscle atrophy side. is more predisposed contractures and
visible to skin breakdown and footdrop and
 Limited range of pressure ulcers. maintain skin
motion >Monitor vital signs integrity of the
regularly. >Provides baseline data. patient.

>Elevate arm and hand.

>Promotes venous
return and helps
>Place hard hand-rolls prevent edema
in the palm with fingers formation.
and thumb >Hard cones decrease
opposed. the stimulation of finger
flexion, maintaining
>Place knee and hip in finger and thumb in a
extended position. functional position.
>Maintains functional
>Begin active or passive position.
ROM to all extremities.
Encourage exercises, >Minimizes muscle
such as squeezing atrophy, promotes
rubber ball, and circulation, and helps
extension of fingers and prevent contractures.
legs and feet.
 Cues Diagnosis Rationale Objectives Nursing Interventions Rationale Evaluation

Subjectives:  At the end of all Independent:

Self- care deficit relate Cerebrovascular interventions > Assess abilities and > Aids in anticipating  The family
 “diri na ako to decreased strength accident (CVA, “stroke” the family level of deficit for and planning for members/caregivers
nakakalakat kay ,loss of muscle or “brain attack”) is members/ performing meeting individual able to demonstrate
nag stoke man coordination and pain. injury or death to parts caregivers will ADLs. needs. techniques and
ako” of the brain caused be able to know lifestyle changes to
 “diri na ak by an interruption in how to assist >Advice the caregivers > These clients may meet self-care
nakakag the blood supply to that the patient. to avoid doing things for become fearful and needs.
lugaring pag area causing disability, client that client can do dependent, and  The patient will be
gios, napabulig such as paralysis. for self, providing although assistance is able to perform self-
nala ako tak assistance as necessary. helpful in preventing care activities within
mga asawa”. frustration, it is level of own ability.
important for client to
Objectives: do as much as possible
 Vital signs: for self to
BP- 140/80 maintain self-esteem
 Visible muscle and promote recovery.
atrophy
 Limited range of >teach caregivers to > Clients need empathy
motion maintain a supportive, and to know caregivers
 Cannot perform firm attitude. Allow will be consistent
ADL on her own client sufficient in their assistance.
time to accomplish Enhances sense of self-
tasks. Provide positive worth, promotes
feedback for efforts and independence, and
accomplishments. encourages client to
continue endeavors.
> Assess client’s ability > Client may have
to communicate the neurogenic bladder, be
need to void and inattentive, or be
ability to use urinal or unable to communicate
bedpan. Take client to needs in acute recovery
the bathroom at phase, but
frequent and scheduled usually is able to regain
intervals for voiding if independent control of
appropriate. this function
as recovery progresses.
 Cues Diagnosis Rationale Objectives Nursing Interventions Rationale Evaluation

Subjectives:
 At the end of all Independent:  The patient report
 “Magpaol na an Acute pain as evidenced Systemic inflammatory nursing >Determine specifics of >Facilitates diagnosis of pain or discomfort is
akon mga piil.” by reports of stiffness of process originating in interventions pain, such as location, problem and initiation relieved or
Ngan mayda na ako feet. the synovium the patient will characteristics, of appropriate controlled and
rayuma” or synovial fluid be to know intensity (on a 0 to 10 therapy. Helpful in Verbalize methods
involving connective relief measures. scale), onset, and evaluating effectiveness that provide relief.
tissue and characterized duration. Note of therapy.
Objectives: by destruction and nonverbal cues.
Vs: proliferation of the
BP: 14/90 synovial membrane >Encourage and >Minimizes stimulation
Inflammation of both b. Phagocytosis maintain bedrest during and promotes
lower extremities. produces enzymes acute phase, if relaxation.
within the joint, causing indicated.
inflammation and pain.
>Provide or recommend
nonpharmacological
measures for
relief of pain, such as
relaxation technique.

>Assist client with

ambulation, as needed.

Collaborative:
>Administer analgesics, >Reduce or control pain
as indicated. and decrease
stimulation of the
sympathetic
nervous system.
 Cues Diagnosis Rationale Objectives Nursing Interventions Rationale Evaluation
Subjectives:
 “Magpa-ol ngan Ineffective role Independent:
maul-ul an akon performance related to  At the end of all >Encourage >Provides opportunity  The patient will
mga tuhod ngan changes in ability to nursing verbalization about to identify fears or verbalize increased
tiil” perform usual tasks or interventions concerns of disease misconceptions and confidence in ability
 “nagtutungkod activities of daily living. the patient will process deal with them directly. to deal with illness,
nala ako para la able to cope and future expectations. changes in lifestyle,
makatukod ako with the illness and possible
kun naglalakat”. and gain >Set limits on >Helps client maintain limitations.
 “diri na ako naka confidence. maladaptive behavior. self-control, enhancing
gios o Assist client to identify self-esteem.
nakahihimo hit positive behaviors that Enhances feelings of
akon mga will aid in coping. competency and self-
hirimuon ha Involve client in worth and encourages
adlaw-adlaw.” planning care and independence and
scheduling activities. participation in therapy.

Objectives: >Assist with grooming >Maintaining

 Pain scale of 6-7 needs, as necessary. appearance enhances
 Give positive self-image.
reinforcement for Allows client to feel
accomplishments. good about self.
Reinforces positive
behavior. Enhances
confidence.