LIST OF NURSING PROBLEM

Problem Identified

Acute Pain related to joint inflammation

Impaired skin integrity related to decreased physical mobility
Disturbed sleep pattern related to physical discomfort
Powerlessness related to debilitating health condition
Risk for infection related to increased blood glucose level
Knowledge Deficit related to Dietary modifications and insufficient knowledge on insulin administration
 NURSING CARE PLAN NO.1

Assessment Nursing Planning Nursing Rationale Evaluation

(Cues) Diagnosis (Desired Interventions
Outcomes)
INDEPENDENT
Subjective Cue: Acute Pain related to Short Term Goal: NURSING After 5 hours of nursing
“Sakit ako paa, maglisod joint inflammation Within 5 hours of INTERVENTIONS interventions, the patient
kog lakaw” as verbalized nursing interventions, 1. To promote optimal was able to verbalized
by the patient. the patient will be able 1. Reposition the patient in patient comfort and decrease intensity of pain
to verbalize decrease his comfortable position reduce anxiety. from a pain scale of 8/10
Pain scale of 8/10 intensity of pain by a to 6/10.
pain scale rating of 2. Non-pharmacologic
Objective Cue: 6/10. 2.Apply cool compress to the interventions such as Goal met.
o Uric Acid – 11 painful joint the application of cool
mg/dL compresses can reduce
o Guarding behavior inflammation and PGRivas,
o Limited soothe burning FSUU/SN
movement sensations.
o Facial grimace
o Fatigue 3. Elevating the
3.Elevate the limb affected joint can help
reduce inflammation.

4. Gout attacks can be

minimized by reducing
4.Advise the patient to adjust risk factors such as the
lifestyle behaviors intake of sugary drinks
and high-purine foods
such as red meats and
some seafood.

5.To prevent fatigue

5. Encourage adequate rest that can impair ability
periods. to manage or cope with
pain

6. Explain the importance of 6. Drug therapy should

therapeutic management to be given in correct
gout. dosage to maintain the
therapeutic outcome to
the patient.
DEPENDENT NURSING
INTERVENTION

7.Administer pain medication 7. Tramadol is used to

as prescribed such as treat moderate to severe
tramadol PRN via IVTT pain.
 NURSING CARE PLAN NO.2

Assessment Nursing Planning Nursing Rationale Evaluation

(Cues) Diagnosis (Desired Interventions
Outcomes)
INDEPENDENT
Subjective Cue: Impaired skin Short Term Goal: NURSING Within 5 hours of
“Init akong likod sige’g integrity related to Within 5 hours of INTERVENTIONS nursing intervention, the
higda.” decreased physical nursing intervention, 1. To improve patient was able to:
mobility the patient will be able 1. Encourage and assist the circulation, reduce -Report a decrease in
Objective Cue: to: patient with turning, pressure on bony skin discomfort.
Dry and flaky skin -Maintain skin integrity repositioning, and mobility prominences, and -Maintain skin integrity
Discomfort Prolonged -Prevent further skin every 2 hours. prevent skin and the skin was well
bed rest breakdown breakdown. moisturized.
-Relieve discomfort
2. Keep the skin moisturized 2. Reduce dryness and Goal Met.
using a hypoallergenic skin prevent skin cracking,
lotion. which could lead to JMRayco/FSUU/SN
skin breakdown.

3. Teach patient and their 3. Proper skin care can

family about the importance help to maintain skin
of proper skin care. integrity and prevent
further skin breakdown.

4. Reassess the patient's skin 4. To monitor the

regularly and document patient's progress and
findings. ensure that
interventions are
effective.

5. Clean, dry, and moisturize

skin, particularly bony 5. Smooth, supple skin
prominences, twice daily or is more resistant to
as indicated by incontinence injury.
or sweating.
 NURSING CARE PLAN NO.3

Assessment Nursing Planning Nursing Rationale Evaluation

(Cues) Diagnosis (Desired Interventions
Outcomes)
INDEPENDENT
Subjective Cue: Disturbed sleep Short Term Goal: NURSING Within 5 hours of
“Wala koy tarong tulog pattern related to Within 5 hours of INTERVENTIONS 1. To determine the nursing intervention, the
kay sakit akong tiil” physical discomfort nursing intervention, effectiveness of pain patient: -Reports reduced
the patient will be able 1. Assess pain level and management strategies discomfort and improved
Pain scale 8/10 to: document every 4 hours. and make necessary sleep pattern, with a
-Maintain a comfortable adjustments. decrease in pain level of
Objective Cue: sleep pattern 6/10. The patient also
Lab result -Reduce pain and 2. Encourage the use of 2. To reduce stress and reports increased comfort
-Blood uric acid: discomfort relaxation techniques such as promote relaxation for
8.9mg/dl deep breathing and sleep. Goal Met.
-Restlessness progressive muscle
-Limited mobility relaxation. JMRayco/FSUU/SN
-Facial grimace
-Discomfort 3. Provide a comfortable and 3.To create a conducive
quiet sleeping environment environment for sleep
by adjusting lighting, room
temperature, and noise level.

4. Encourage the use of a 4. To reduce pressure

supportive pillow for the knee on the affected areas
and toe to reduce discomfort. and promote comfort
during sleep.

5. Assess fluid intake and 5. To reduce uric acid

encourage adequate levels and reduce pain.
hydration.

6. Provide education
(independent) on the 6. To prevent future
importance of maintaining a gout flares and promote
healthy diet, weight control, overall health.
and physical activity to
prevent gout flares.

DEPENDENT NURSING
INTERVENTIONS

7. Administer prescribed pain 7. To relieve pain and

medication 30 minutes before promote sleep.
bedtime.
 NURSING CARE PLAN NO.4

Assessment Nursing Planning Nursing Rationale Evaluation

(Cues) Diagnosis (Desired Interventions
Outcomes)
Short Term Goal: INDEPENDENT NURSING Within 5 hours of
Subjective Cue: Powerlessness related Within 5 hours of INTERVENTIONS nursing interventions,
The patient reports “wala to debilitating health nursing interventions, the patient was able to
naman koy mahimo, mao condition the patient will be able 1. Encourage verbalization of 1. This approach creates express sense of control
naman ni pagbout sa to: feelings, thoughts, and a supportive environment over the present
Ginoo” concerns about making and sends a message of situation and future
-Express sense of decisions. caring. outcome and
Objective Cue: control over the present acknowledge reality
o Seen to be always situation and future 2. Gestures and that some areas are
in deep thought outcome 2.Note nonverbal behavioral nonverbal cues are beyond individual’s
o Dependence on responses significant in looking control as she was able
others -Acknowledge reality deeper into what a person to verbalize “Lage,
that some areas are feels. It is one important samtang naa pako diria
beyond individual’s way of expressing one’s mo laban ko kay naa pa
control feelings. akong pamilya nga
permi mo suporta og
3. Review of past coping bantay nako.
3. Encourage patient to experiences and prior Maningkamot ko ma
identify strengths. decision-making skills arang-arang.”
may assist the patient to
recognize inner strength. Goal met.
Self-confidence and
security come with a PGRivas,
sense of control. FSUU/SN

4. Show concern for patient as 4. To make the patient

a person. feel that he is not alone
and to increase his self-
esteem.

5.Discuss with the patient 5. Allowing the patient to

concerning his care (e.g., participate in discussions
treatment options) will increase his or her
sense of independence or
autonomy.

6. Avoid using coercive power 6. This approach may

when approaching the patient. increase the patient’s
feelings of powerlessness
and result in decreased
self-esteem.

7.Encourage client to maintain 7. To promote optimism

a sense of perspective about and positive outlook
the situation towards life.

8.Encourage use of anxiety 8. To promote wellness.

and stress-reduction
techniques such as thinking of
happy thoughts and positive
self-recitation
 NURSING CARE PLAN NO.5

Assessment Nursing Planning Nursing Rationale Evaluation

(Cues) Diagnosis (Desired Interventions
Outcomes)
INDEPENDENT
Subjective Cue: Risk for infection Short Term Goal: NURSING After 5 hours of nursing
“Naa koy diabetes ug related to increased After 5 hours of nursing INTERVENTIONS interventions, the
nagpakpak akong mga blood glucose level interventions, the 1. Early diagnosis and patient was able to
panit.” as verbalized by patient will be able to 1. Monitor for the signs of treatment of infections identify interventions to
the patient identify interventions to infection and inflammation: can control their severity prevent/reduce risk of
prevent/reduce risk of fever, flushed appearance, and decreases infection.
Objective Cue: infection. wound drainage, purulent complications. Patients
WBC- 10.80 109/L sputum, cloudy urine, with diabetes may be
Blood Glucose- 106 increased WBC admitted with infection,
Dry flaky skin which could have Goal met.
Lymphocytes - 9 (20-50) precipitated the
BUN - 0 (0.02-0.05) ketoacidosis state.
Monocytes - 4 (8-14) KVillezon,
-With urinary catheter 2. Maintain asepsis of 2. Increased glucose in FSUU/SN
urinary catheter, IV site, the blood creates an
administration of excellent medium for
medications, and providing immune dysfunction and
skin care. for pathogens to thrive.

3. An impairment or
3. Provide meticulous ineffective peripheral
skincare by gently massaging circulation can place the
bony areas, keeping skin patient at risk for
clean. Keep linens dry and increased skin
wrinkle-free. breakdown and the
development of
infection.

4. Hand washing and

4. Wash your hands and use using aseptic technique
aseptic technique for nursing reduces the likelihood of
tasks involving non-intact transmitting pathogens to
skin or invasive lines. Instruct the patient that can cause
also family to wash hands. infection.

5. Reducing visitation
5. Instruct patient and family reduces the chance of
to limit visitors and/or use spreading pathogens to
protective isolation for the patient
patients who are at risk for
infection.
6. It is important to
6. Teach the patient, family, recognize signs of
and caregivers signs and infection early in order
symptoms of infection and to seek prompt
when to contact a healthcare treatment.
provider.
7. The immune system
7. Encourage the intake of is more responsive and
calorically dense and protein effective when
rich foods. nutritional status is
sufficient.

.
 NURSING CARE PLAN NO.6

Assessment Nursing Planning Nursing Rationale Evaluation

(Cues) Diagnosis (Desired Interventions
Outcomes)
INDEPENDENT
Subjective Cue: Knowledge Deficit Short Term Goal: NURSING 1. Patients who are After 5 hours of nursing
“Call center agent ko related to Dietary After 5 hours of nursing INTERVENTIONS recently diagnosed with interventions, the patient
sauna ug permi ko modifications and interventions, the diabetes often go was able to demonstrate
gakaon ug mga tam is insufficient patient will be able to 1. Assess the patient’s and through various stages knowledge about disease,
kay para maenergize ko. knowledge on disease demonstrate knowledge family’s readiness to learn of the grieving process. insulin injection, and
Wala sab ko kabalo and insulin about disease and before initiating an education healthy diet
unsaon pagcontrol sa administration insulin injection, and plan.
blood sugar parehas healthy diet 2. Many patients with
anang mag insulin“as 2. Assess the skills and self- diabetes make errors in
verbalized by the patient care behaviors of patients self-care, and Goal met.
who’ve had diabetes for reassessment is a must
Objective Cue: many years. to determine their
Blood Glucose- 106 competency in self-care KVillezon,
-patient is not and other preventive FSUU/SN
knowledgeable about his measures to prevent
diet complications.
- Insufficient or no
awareness of necessary 3. Help patient understand 3. Monitoring provides
information or skill to and demonstrate the data on the degree of
attain or maintain a technique and timing of home glucose control and
desired health status monitoring of glucose. identifies the need for
-On no pork and beef, no changes in insulin
fruits, no red meat diet dosage.
-no softdrinks and fruit
juices, no 3 in 1 coffee or
any herbal drinks, no 4. Teach patient about 4. Making the right
pastries, halo-halo, ice appropriate diet to manage food choices is an
cream and chocolates, no increased blood glucose level. important way to keep
fast food your blood sugar at a
healthy level and
maintain healthy weight

5. Explain the importance of 5. To help prevent

choosing the right kind and diabetes from
amount of food to consume worsening or develop
further complications

6. Teach the patient to follow 6. A diet low in fat and

a low in simple sugars, low in high in fiber helps to
fat, and high in fiber and control cholesterol and
whole grains. triglycerides. Three
daily meals and an
evening snack are
recommended. Refined
and simple sugars
should be reduced, and
complex carbohydrates,
such as cereals, rice
should be increased.

7. Provide written 7. Reinforces learning

information about diabetes and conveys the
management for the patient to maximum amount of
refer to. information.

DEPENDENT NURSING
INTERVENTION
8. Following specific
8. Instruct patient to follow diet and taking insulin
prescribed diet and take is ideal for preventing
insulin as prescribed blood sugar spikes after
you eat