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Assessment Subjective data: kanang mura ug gikalitan ug tusok nga kanang sakit jud basta kay sakit jud eh lihok-lihok mao na nga gapuyo nalang jud ko sa akong katre para mawala-wala pud ang kasakit as verbalized by the client. Diagnosis Pain related to multiple stab wounds Planning Short term: after 5 minutes of nursing intervention the client will be able to: y report pain is relieved or controlled y verbalize nonpharmacologic methods that provide relief y demonstrate use of relaxation skills and diversional activities as indicated for situation Long term: After 1 hour of nursing interventions the client will be able to: - nonrecurrence of pain y demonstrate use of relaxation skills and diversional activities as Interventions Independent: Encourage verbalization of feelings about pain Provide comfort measures, such as: touch, repositioning, use of heat or cold packs, quiet environment and calm activities Instruct in and encourage use of relaxation techniques, such as focused breathing, imaging Encourage diversional activities Review procedures and expectations including when treatment may cause pain Encourage adequate rest periods to reduce concern of the unknown and associated muscle tension to prevent fatigue Rationale Evaluation Short Term: The Client was able to verbalize relief from pain and used nonpharmacologic methods to relieve it. And was able to correctly demonstrate relaxation skills and diversional activities.

To lessen anxiety

to promote nonpharmacologic pain management

to distract attention and reduce tension

Objective data: y Pain scale of 7 out of 10 y guarding behaviour y protective gestures y facial grimacing y diaphoresis y change in vital signs: HR= 94bpm, RR= 25cpm

Long Term: Pain was further controlled by its nonrecurrence and client was able to effectively use diversional and relaxation skills in every event of pain.

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indicated for situation Provide for individualized physical therapy or exercise program that can be continued by the client after discharge Discuss with SO(s) ways in which they can assist client and reduce precipitating factors that may cause or increase pain Promotes active, rather than passive, role and enhances sense of control Family support can reduce anxiety and therefore reduces pain felt by the client

Collaborative: Administer analgesics, as indicated, to maximum dosage - to maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal.

To provide a pharmacologic pain management when pain cannot be reduced by other measures used.

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Assessment Subjective data: Headache Diagnosis Inadequate thermoregulation related to trauma and exposure to Planning
Short Term: After of nursing interventions the client will be able to: y Maintain core temperature within normal range y be free of seizure activity y identify underlying cause or contributing factors and importance of treatment as well as signs/symptoms requiring further evalution or intervention Long Term: After of nursing interventions the client will be able to: y Demonstrate behaviors to monitor and promote normothermia y be free of complications such as irreversible braim or neurological damage, acute renal failure

Interventions Independent: y Promote surface cooling by means of undressing y provide cool Environment and/or fans y cool, tepid sponge baths or immersion y provide local ice packs, especially in groin and axillae Maintain Bedrest Discuss importance of adequate fluid intake

Rationale

Evaluation Short Term: Temperature is within normal range as evidenced by T=

Objective data: Body Temp: flushed skin Warm to touch tachycardia

heat loss by radiation and conduction heat loss by convention heat loss by evaporation and conduction these are areas of high blood flow to reduce metabolic demands and oxygen consumption to prevent dehydration

y y

Collaborative: Monitor use of hypothermia blanket and wrap extremities with bath towels Provide high-calorie diet

to minimize shivering

Long Term: The client was able to correctly demonstrate behaviors on how to control hyperthermia and was free from any complications.

to meet increased metabolic demands

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Assessment Subjective data: Nadunggaban man ko mam ikapila dani sa likod as verbalized by the client Objective data: y Multiple stab wound, paravertebral line T4 level; 7th MCL y Disruption of skin surface at the y Wound is (mm diam) y localized erythema y purulent discharge y (+) pain y (+) pruritus Diagnosis Impaired Skin integrity related to mechanical multiple trauma secondary to multiple stab wounds Planning Interventions Rationale Evaluation Short Term: Long Term:

Short term: Independent: After of nursing - Describe and intervention the client will measure wounds be able to display and observe imporovement in wound changes healing as evidenced by: - Promote optimum nutrition with highy intact skin or quality protein and minimized sufficient calories, presence of wound vitamins, and y absence of mineral redness or supplements erythema - Encourage y verbalize adequate understanding of adequate periods condition and of rest and sleep causative factors y identify interventions - Limit or avoid use appropriate for of caffeine , specific condition alcohol, and y Demonstrate medication behaviours and affecting REM lifestyle changes to sleep promote healing and prevent - Provide teaching complications or on oral hygiene, recurrence avoiding extremes of hot or cold,

to facilitate healing

to limit metabolic demands,maximizi ng energy available for healing, and meet comfort needs May be necessary to determne extent of impairment to prevent damage to mucous membranes

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changing position or tube, lubricating lips Promote Early mobility. assist with or encourage position changes , active or passive and assistive exercises Practice Aseptic technique for cleansing, dressing, or medicating lesions to promote circulation and prevent excessive tissue pressure.

Long Tem: After of nursing interventions the client will be able to: y Wound is less than ---y Display progressive improvement in wound or lesion healing y Be infection free until client is discharged

Reduce risk of crosscontamination

Collaborative: - Assist with diagnostic procedures - Provide appropriate protective and healing devices (e.g., padding or cushions.therapeuti c bed and mattresses, chronic ulcer dressing , compression wrap.

May be necessary to determne extent of impairment To prevent further damage or complication to existing problem.

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Assessment Subjective data: Nadunggaban man ko mam ikapila dani sa likod as verbalized by the client Objective data: y Multiple stab wound, paravertebral line T4 level; 7th MCL y Disruption of skin surface at the y Wound is (mm diam) y localized erythema y purulent discharge y (+) pain y (+) pruritus Diagnosis Impaired Skin integrity related to mechanical multiple trauma secondary to multiple stab wounds Planning Interventions Rationale Evaluation Short Term: Long Term:

Short term: Independent: After of nursing - Describe and intervention the client measure wounds will be able to display and observe imporovement in wound changes healing as evidenced by: - Promote optimum nutrition with highy intact skin or quality protein and minimized sufficient calories, presence of wound vitamins, and y absence of mineral redness or supplements erythema - Encourage y verbalize adequate understanding of adequate periods condition and of rest and sleep causative factors y identify interventions - Limit or avoid use appropriate for of caffeine , specific condition alcohol, and y Demonstrate medication behaviours and affecting REM lifestyle changes sleep to promote healing and prevent - Provide teaching complications or on oral hygiene, recurrence avoiding extremes

to facilitate healing

to limit metabolic demands,maximizi ng energy available for healing, and meet comfort needs May be necessary to determne extent of impairment to prevent damage to mucous membranes

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Assessment Subjective data: atong tuig 1995 naaksidente ko kay nahulog ko sa akong gi trabahoan nga construction nabali ni akong wala nga tiil gi dala ko diri sa provincial na operahan gani ko ato na, naa nay steel plate ni akong wala nga tiil unya kung ting tugnaw musakit ni siya lisod jud para sa ako Diagnosis Impaired physical mobility related to decrease muscle strength ,control, or mass: joint stiffness, contractures: Pain musculoskeletal impairment Planning Short Term: After of nursing interventions the client will be able to: y Verbalize Long Tem: understanding After of nursing of situation and interventions the client individual treatment will be able to: regimen and safety y measures less Wound is y Demonstrate than ---y techniques or Display behaviours that progressive enable resumption of improvement in activities wound or in ADLs y participate lesion healing and desired activities y Be infection free Long Term: until client is After of nursing discharged interventions the client will be able to: y participate in ADLs and desired activities y Maintain position function and skin integrity as evidenced by y Maintain or increase strength and function of affected and/or of hot or Interventions cold, Rationale changing position Independent:lubricating - to promote or tube, y Assist or have client circulation and lips reposition self on a prevent excessive tissue pressure. - regular schedule Promote Early - for position y Instruct in assist use of mobility. changes and siderails, overhead with or transfers trapeze encourage position changes , - to maintain position y Support affected body active joints using of function and parts or or passive reduce pressure and assistive pillows,rolls,foot ulcers supports exercises y - Provide Passive ROM - Reduce risk of Practice Aseptic exercises for crosstechnique y Provide regular skin contamination cleansing, care to include dressing, or pressure area medicating managementlesions Collaborative: activities y Schedule - to reduce fatigue - with adequate rest Assist with periods during the diagnostic day procedures y - Encourage Provide appropriate - - May be necessary enhances selfparticipation in selfprotective and toconcept and sense determne extent care: diversional or healing devices ofof independence impairment recreational activities (e.g., padding or - To prevent further y Provide client with cushions.therapeuti damage or ample time to perfrom c bed and complication to mobility-related tasks existing problem. mattresses, chronic y Provide safety ulcer dressing , measures including environmental wrap. compression management and fall Evaluation Short Term: The client was able to state correct safety measures , demonstrated techniques to resume activites

nga ako lang mag lihok-lihok kinahanglan pa jud nako ug tabang kung naa man koy buhaton kay dili jud nako makaya nga ako ra

Long Term: Maintained position function, skin integrity as evidenced by ---and there was an increase in strength and function of affected body part.

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Objective data: y Limited range of motion y Limited ability to perform gross or fine motor skills y difficulty turning y decreased or slow reaction time y the patient cant lift his lower extremities on his own he needs assistance in lifting himself up compensatory body part y prevention Encourage adequate intake of fluids and nutritious foods Encourage clients SOs involvement in decision making as much as possible Review Safety measures such as transfers Promotes wellbeing and maximize energy production Enhances commitment to plan, optimizing outcomes

Collaborative: y Assist with treatment of underlying condition causing pain and/or dysfunction Administer medications prior to activity as needed for pain relief Consult with physical or occupational therapist to permit maximal effort and involvement in activity to develop individual exercise and mobility program, and identify appropriate mobility devices

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Assessment Subjective data: Objective data: Diagnosis Risk for deficient Fluid volume Planning Short Term: Long Term: Interventions Independent: Collaborative: Rationale Evaluation Short Term: Long Term:

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Assessment Subjective data: Objective data: Diagnosis Risk for Infection related to multiple stab wounds and pressure ulcers inadequate primary defences tissue destruction trauma insufficient knowledge to avoid exposure to pathogens Planning Short Term: After 1 hour of Nursing Interventions the client will be able to: Verbalize understanding of individual causative or risk factors. identify interventions to prevent or reduce risk of infection demonstrate techniques, lifestyle changes to promote safe environment be afebrile Interventions Independent: y Stress Proper hand hygiene by all caregivers between therapies and clients y Maintain Sterile Technique for all invasive procedures y Provide Tepid Sponge Bath y Change surgical or other wound dressings,as indicated using proper technique for changing / disposing of contaminated materials y Cover perineal and pelvic region dressings with plastic when using bedpan y Encourage early ambulation, deep breathing .coughing,position changes y Maintainn Rationale Evaluation Short Term: The patient was able to verbalize understanding of individual causative or risk factors and stated ways to prevent infection

first line of defense against healthcare associated infections (HAIs)

Long Term: After of nursing interventions the client will be able to: achieve timely wound healing; Client will be infection free until patient is discharged.

to prevent contamination

Long Term: The client was able to achieve timely wound healing and was discharged free from infection(s).

for prevention of aspiration/respirato ry infections

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adequate hydration, stand or sit to void, and catheterize Provide regular urinary catheter and perineal care Emphasize necessity of taking antivirals or anirbiotics, as directed to avoid bladder distention and urinary stasis

Reduces risk of ascending UTI Premature discontinuation of therapy when client begins to fell well may result in return if infection and potentiation of drug-resistant strains

Collaborative: - Assist with medical procedures - administer and monitor medication regimen - Administer prophylactic antibiotics - Identify resources available to the individual

to determine effectiveness of therapy or presence of side effects

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other Diagnoses: Risk for deficient Fluid volume risk for post-trauma syndrome