DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE
Subjective Anxiety (mild) related to Anxiety is a negative Short term 1. Made an environment Patient’s environment is an
“Wala ko kasabot sa ako gi stress and change in health emotional response to Patient will verbalize conducive for resting aspect that can be
bati. Gi kulbaan ko nya status threatening circumstances. awareness of feelings of manipulated to enhance
nahadlok sad ko,” as State anxiety can be anxiety, and appear relaxed comfort, therefore
verbalized by the patient. conceptualized as “a state in and report that anxiety is decreasing anxiety
which an individual is unable reduced to a manageable
Objective to instigate a clear pattern of level 2. Advised s/o to be present This provides comfort and
-Increased HR (114 bpm) behavior to remove or alter during procedure assurance to the patient
-Increased RR (24 cpm) the Long term thereby lessening anxiety
event/object/interpretation Patient will identify and
that is threatening an apply healthy ways to deal 3. Positioned patient Provides non-
existing goal.” Anxiety is with and express anxiety, comfortably pharmacological pain
associated with elevated and use resources/support management
high blood pressure, systems effectively
increased heart rate, and an 4. Discussed age-appropriate Limits dwelling on, or
enhanced respiratory rate. activities for distraction with transcend unpleasant
patient such as listening to sensations or situations
(https://www.ncbi.nlm.nih.g music, reading, talking to
ov/pmc/articles/PMC472674 s/o’s, and watching
9/ television or movies
5. Scheduled activities to
promote relaxation and Prevents fatigue and
sleep promotes relaxation
DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE
Sujective Impaired Skin Integrity r/t Skin is the primary defense Short term 1. Advised patient to keep To reduce risk of dermal
“Nikalit ra man nig gawas na alteration in skin appearance of the body; it protects the Patient will be able to nails short. injury when severe itching is
mga spots nya katol pa jud.” as manifested by presence of body against infections and demonstrate behaviors or present.
purpuric lesions in the arms, diseases brought about by techniques to prevent skin
Objective legs, and abdomen s/t the invasion of microbes in breakdown. 2. Advised patient to keep To prevent further invasion
Presence of purpuric lesions bacterial meningitis the body. A normal skin is the affected area clean and of microorganisms.
in the arms, legs, and moist and intact; dryness of Long term dry.
abdomen the skin is more prone to No skin breakdown will be
friction that may result to noted. 3. Instructed patient to Moisture potentiates skin
impairment of the skin remove or avoid using breakdown.
integrity as compared with a we/wrinkled linens
moist skin.
4. Instructed patient not to To prevent skin irritation.
(https://www.scribd.com/do use tight clothes.
c/93644932/NCP3-Skin-
Integrity) 5. Administered triderm as To decrease irritable itching.
ordered.
DEFINING CHARACTERISTICS NURSING DIAGNOSIS SCIENTIFC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE
Subjective Acute Pain r/t meningeal Acute Pain is referred to as Short term 1. Assessed pain score. To have a basis as to the kind
“Nikalit ra man ug sakit irritation as evidenced by the unpleasant sensory and Patient will be able to report of interventions to be given
akong ulo ug liog ig padung headache secondary to emotional experience arising concerns about the pain and
nako diri,”as verbalized by bacterial meningitis from actual or potential will express feelings of When the meninges of the
the patient. tissue damage or described comfort and relief. 2. Assessed for photophobia brain become infected, it can
in terms of such damage; lead to hypersensitivity to
Objective sudden or slow onset of any Long term brigt lights also known as
Headache intensity from mild to severe Patient will be able to photophobia.
Facial grimace with anticipated or demonstrate ways on how to
predictable end and a relieve the pain if ever it These are used to assess for
duration of <6 months. occurs again. 3. Assessed for Kernig’s sign any sign of meningeal
(pain and resistance on irritation.
(https://nurseslabs.com/me passive knee extension with
ningitis-nursing-care- hips fully flexed) and
plans/3/) Brudzinki’s sign (hips flex on
bending the head forward).
4. Maintained a quiet
environment and keep Darkening the room may
patient’s room darkened. decrease photophobia.
5. Controlled environment to
encourage rest. Environmental changes such
as increased noise and
glaring light cause sensory
overload that promotes
cerebral irritation leading to
convulsions.
6. Assisted in ROM exercises. Prevent joint stiffness and
neck pain.
7. Administered antibiotic
and corticosteroid as Antibiotic and corticosteroid
prescribed. therpay are used to reduce
the inflammation and
therefore decrease pain.
8. Administered analgesics NSAIDs are given to relieve
such as acetaminophen or pain.
NSAIDs as prescribed.
