Assessment/Cues Subjective Cue(s) Ang sakit ng tuhod at braso ko as verbalized by the patient pain 8/10 scale-

Nursing Diagnosis

Planning/Goal of Care Within 30 minutes of nursing intervention, client will report that pain decreased from 8 to 2.

Implementation/Intervention

Evaluation

with guarding behavior with reluctance to attempt movement; limited ROM with distracted behavior Facial Grimace
RR-27 cpm

Acute pain related to inflammatory process secondary to disease condition as evidenced by: pain scale-8/10 with guarding behavior with reluctance to attempt movement; limited ROM with distracted behavior Facial Grimace RR-27 cpm

Independent Functions: Monitored vital signs R: baseline data Investigate reports of pain, noting location and intensity (scale of 0-10), note precipitating factors and nonverbal cues. R : Helpful in determining pain management and effectiveness of interventions. Encouraged to use relaxation techniques (focus on breathing, listening to music) R: Distract attention away from pain Encouraged adequate rest periods R: prevent fatigue Maintain bed rest or chair rest whenindicated. Bed rest may benecessary to limitpain/injury to joints.

After 30 minutes of nursing intervention, client reported that pain decreased from 8 to 2 as evidenced by: Pain scale of 2 (-)facial grimace ()restless ness Goals met.

 Place pillows on affected area. Rests painful and maintains neutral position. Encourage frequent changes of position to move in bed, supporting affected joints above and below, avoiding jerky movements. Prevents general fatigue and joint stiffness, stabilizes joint, decreasing joint movements and associated pain. Involve in diversional activities appropriate for individual situation ,e.g., coloring of books, playing with toys Refocuses attention,provides stimulation,and enhances self-esteem and

feelingsof general well-being.

Dependent: 1.Administered Ibuprofen 5mL TID as prescribed R: to relieve pain

Assessment/Cues

Nursing Diagnosis

Planning/Goal of Care At the end of the nursing interventions, the patient will regain/maintain mobility at the highest possible level.

Implementation/Intervention

Evaluation At the end of the nursing interventions, the patient regain/maintain ed mobility at the highest possible level as evidenced by: Naigagalaw ko na tuhod at braso ko ng walang sakit

Subjective: Hindi ako masyadong makalakad.hirap akong igalaw ang braso ko as verbalized by the patient O bjective: with reluctance to attempt movement; limited ROM with decreased muscle strength /control inability to move purpose fully within the physical environment, imposed restriction

Impaired physicalmobility related to pain/discomfort as evidenced by: with reluctance to attempt movement; limited ROM with decreased muscle strength /control inability to move purpose fully within the physical environment, imposed restrictions

Assess degree of immobility produced by pain. Level of activity/exercise depends on progression/resolution of inflammatory process. Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility. Encourage patient to maintain upright and erect posture when sitting, standing, and walking. Maximizes joint function, maintains mobility. Discuss/provide safety needs, e.g., raised side rails. Helps preventaccidental injuiries/fall

Assessment/Cues Namamagayung tuhod at braso ko. asverbalized Objective:

Nursing Diagnosis

Planning/Goal of Care At the end of the nursing interventions, the patient will be able to maintain tissue perfusion as evidenced by palpable pulses, skin warm, normal sensation and stable vital signs

Implementation/Intervention

Evaluation At the end of the nursing interventions, the patient was able to maintain tissue perfusion as evidenced by palpable pulses, skin warm, normal sensation and stable vital signs

swelling of the left leg and forearm CRT 2secs

Risk for peripheral neurovascular dysfunction Related to interruption of blood flow secondary to disease condition as evidenced by: swelling of the left leg and forearm CRT 2secs

Assess general condition of and contributing factors to patient. Provide basis for understanding general, current situation of client. Evaluate presence/quality of peripheral pulse distal to injury via palpation. Decreased/absent pulse may reflect vascular injury and necessitate immediate medical evaluation of circulatory status. Assess capillary return, skin color, and warmth distal to inflammation. Return of color should be rapid (3-5 secs.).White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment. Maintain elevation of inflamed extremity unless contraindicated by confirmed presence of compartmental syndrome.

 Promotes venous drainage/decreases edema. Investigate sudden signs of limb ischemia, e.g., decreased skin Temperature, pallor, and increased pain. Osteomyelitis may cause damage to adjacent arteries, with resulting loss of distal blood flow. Encourage patient to routinely exercise digits/joints distal to inflammation Enhances circulation and reduces pooling of blood, especially in the lower extremities