Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective:  Pain related to Short Term Goal:  Focus  To rule out  The patient
“Sumsakit ang likod loss of integrity  After 1 hour of performing pain worsening of condition is
ko” as verbalized by of bone nursing assessment underlying improved.
the patient. structure. intervention the each time the condition/
patient will pain occurs. development of
Objective: report pain is complication.
 Grimace in controlled.
pain.  Observation
 Sharp pain felt Partially  Focus in may/ may not
when the Compensatory observation – be congruent
patient moves. verbal cues. with verbal
 Pain scale of reports
7/10. indicating need
for further
evaluation.

 Facilitate in
encouraging  To lessen pain.
deep breathing
exercise.

 Facilitate  To prevent
encouraging fatigue.
adequate rest
period,  To maintain
 Facilitate acceptable
administering level of pain.
analgesic as
indicated to
maximal
dosage as
needed.
 Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Subjective:  Impaired physical Long Term Goal:  Focus in noting  Feeling of  The patient condition
“Hindi na ako mobility related to loss  After 8 hours of emotional and frustration may maintained.
makalakad” as of integrity of the bone nursing intervention behavioral responses impede
verbalized by the structure. the patient will to problem of attainment of the
patient. verbalized of immobility. goal.
understanding of
Objective: the situation and  Focus in racing the
 Limited range of safety measure. side race overhead  For safety.
motion. trapeze roller pads
 Slowed
movement.
 Difficulty in  Focus in supporting
turning. the affected body, air  To reduce risk of
 Limited ability to mattress, water bed pressure sore.
perform the and so forth.
motor skills.
 Facilitate in
encouraging  Enhance self-
participation in self- concept and
care diversional and sense of
recreational activities. independence.
Generic Name Brand Name Classification Dosage Mechanism of Indication Contraindication Side Effect Nursing
Action Consideration
 Celecoxib  Celebrex  Anti –  200mg./  Inhibits  Acute  Severe  Dizziness  Monitor
inflamma cap BID prosta- pain in hepatic  Head ache CBC
tory glandin adults, impairem  Nausea and  Take with
analgesi synthesis, relief ent, vomiting. food.
c. primarily sign and allergic  Assess for
ny sympto reaction liver
inhibiting ms of to dysfunctio
cyclo- spondylit sulfonomi n
oxygenes its. de, use in  Do not
e-2 (COX- late take
2) pregnanc aspirin or
y aspirin
containing
product
with out
consent.
Generic Name Brand Name Classification Dosage Mechanism of Indication Contraindication Side Effect Nursing
Action Consideration
 Tramadol  Ultram  Analgesic  PRN q  Centrally  Management  Hypersensitivity  Dizziness  Check 5
8º acting for moderate to tramol use  Vertigo R’s
analgesic pain with great  Headache  Take
not cautions in  Vomiting only as
related those taking  Nausea directed
chemical MAO inhibitors. .
to opates  May be
it may taken
bind to w/o
mu-opoid meals.
receptors  Report
and inhibit lack of
uptake of respons
nor- e.
ephinephr  Drug
ine and may
serotonin. cause
drowsin
ess.
 VMMC

Department of Pathology

Biochemistry

Patient’s Name : Desreza, Crisanta Date: 02/16/11 Physician Name:Nichols M. Bountia

RESULT

Test Name Result Units Reference Range

Urea 3.1 Mg/dl 3.00-8.10
Creatinine 0.6 Mg/dl 0.70-1.30
Glucose 87 Mg/dl 65.0-125
Sodium 154 Mg/dl 136.0-144
Chloride 97 Mg/dl 99.0-108
Calcium 2.11 Mg/dl 8.90-10.3
Potassium 4 Mg/dl 3.60-5.10
 HEMATOLOGY

Patient’s Name: Desreza, Crisanta Date: 2/16/11

Clinical Impression: Pott’s Disease

RESULT

WBC 7.66

Segmenter .64
Lympocyte .34
Eosiniphil .02

Hemoglobin 125
Hematocrit 0.36
ESR 0.36
Platelet 263