Subjective data: Acute pain secondary to After 8 hours of INDEPENDENT: After 8º of rendering

surgical procedure rendering nursing 1. Evaluate pain regularly Provide information nursing care, the goals
The patient verbalizes:
(hysterectomy) as noting characteristic, about need for or was met partially as
“Nasakit jay naoperaan” intervention, the
evidence byrepo rted location intensity (0-10). effectiveness of evidenced by:
Objective data: patient will be able to:
intervention.  Decreased
pain with the pain scale
 Reported pain  Decrease pain
of 8 (pain scale from 1 2. Identify specific pain scale to the
with the pain scale scale of 8 to 4 as Prevents undue strain
– 10), limited range of activity limitations. level of 5
of 8 (pain scale evidence by on operative site.
motion and sleep
from 1 – 10) stable vital signs
disturbance patter 3. Reposition as indicated.
 Facial May relieve pain and
grimacing enhance circulation
 Guarding
behavior 4. Encourage of relaxation Relieves muscle and
technique like deep
emotional tension.
breathing exercise.

5. Monitor vital signs

Changes in vital signs
may be used for rough
estimate of pain.

DEPENDENT: DEPENDENT:

1.Administer analgesic To relieve mild or

medication: Ketorolac moderate pain
IVTT x 4 doses q 8 hours
as prescribe by the
physician.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE RATIONALE
Subjective: Pain related to tissue After 8 hours of nursing 1. Change the position -pain is sometimes due Goal met:
“Masaki tang tahi ko” as trauma and incisional intervention, patient’s of the patient to the position of the After 8 hours of nursing
verbalized by the patient discomfort as pain evidenced by pain patient intervention, the
manifested by grimace scale of 7 be reduced to patient reported pain
Objective and pain scale of 7 3 2. Provide comfort -to reduce discomfort was lessened to pain
 Restlessness measures scale of 3
 Irritability
 With cold 3. Assist patient in -to assist in muscle and
clammy skin breathing techniques generalized relaxation
 Excessive
perspiration 4. Provide quiet -for patient
 Facial grimace environment comfortability and
 Pain scale of 7 lessen the discomfort
where 1 is the 5. Relay on the patient -to reduce anxiety felt
least painful and report of pain by the patient
10 is the most
painful 6. Encourage -to divert the attention
 Vital signs as divertional activities from pain to activities
follows:
T = Collaborative
PR= 7. Administer analgesic -usually altered in pain;
RR= as ordered by the To maintain acceptable
BP= attending physician level of pain
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE RATIONALE
Objective: Fluid volume deficit After 8 hours of nursing 1. change dressings -to protect skin and Goal met:
 Poor skin related to the risk of intervention, the frequently monitor losses After 8 hours of nursing
turgor post operative patient will maintain intervention, the
 Dry lips hemorrhage fluid at a functional 2. Provide frequent oral -to prevent injury from patient was maintained
 Weak in level care dryness fluid as manifested by
appearance good skin turgor
 Pale looking 3. Measure input and -to monitor fluids in the
 Vital signs as output body
follows:
T = 4. Monitor v/s -to assess the patient
PR= and it serve as baseline
RR= data
BP= Collaborative:
5.Administer IV fluids as -helps maintain fluids in
 v/s of: indicated the body

6. Give medications as -to reduce blood loss

ordered by the
attending physician
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE RATIONALE
Subjective: Impaired mobility After 8 hours of nursing 1. Provide activities with -to reduce the fatigue Goal met:
“Hindi ako makagalaw related to decreased intervention, the adequate rest period After 8 hours of nursing
ng maayos:, as muscle strength as patient will be able to intervention, the
verbalized by the manifested by limited move safely and 2. Encouraged adequate -promotes well being patient was able to
patient ROM independently intake of fluids and maximize energy move safely and
production independently
Objective: 3. Advise to move hands -to
 Impaired and legs slowly exercise/mobilization of
ability to turns body
side to side
 Cannot eat 4. Encourage -enhances self concept
without participation in self and sense of
support care independence
 Slowed
movement
 Irritable
 Limited ROM
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE RATIONALE
Objective: Infection related to Within 8 hours of shift, 1. Increase oral fluid -frequent urination Goal partially met
 Vital signs as altered physiologic the client will be free intake of 1 t0 2 liters a prevents urine
follows: infection barrier of the from infection day to promote retention that could
T = vaginal environment urination cause bacterial growth
PR= secondary to persistent
RR= uterine bleeding 2.Encourage perineal -reduce risk of
BP= care once a day to contamination or
maintain acidity ascending infection
of the vagina

3.Review self -some drugs can alter

medication regimen bladder and kidney
of the client function