ASSESSMENT

OBJECTIVE DATA
Conscious,
coherent
Appears weak
Paleness noted
Patient
transitioned
only
from
NPO
to
general liquids diet
to soft diet during
hospitalization
not
enough
nutritional value
With contraptions
unable
to
perform
much
activities of daily
living
due
to
contraptions
On complete bed
rest
7 kilogram weight
loss
during
the
course
of
confinement
Current
BMI:
14.82-underweight

NURSING DIAGNOSIS
Imbalanced
nutrition:
less
than
body
requirements related to
decreased oral intake

ASSESSMENT
SUBJECTIVE DATA
Masakit po ang
sugat
ko.
As
verbalized by the

NURSING DIAGNOSIS
Acute Pain related to
tissue injury secondary
to surgical intervention
(as evidenced by pallor;

PLANNING
SHORT TERM GOAL
After 4 hours of
nursing
interventions,
the
patient will have an
improved condition
as manifested by
???

INTERVENTIONS

RATIONALE

INTERVENTIONS
Assess
general
health status.
Assess
pain
parameters
to

RATIONALE
To determine other
contributing
factors
Pain is a subjective

EVALUATION

LONG TERM GOAL

After 24 hours of
nursing
interventions,
the
patient will have an
improved condition
as manifested by
weight gain of more
than 1 kilogram or
return
to
pre
hospitalization
weight.

PLANNING
SHORT TERM GOAL
After 4 hours of
nursing
interventions,
the

EVALUATION

patient
Rated pain as 8/10;
characterized pain
as burning, non
radiating,
continuous,
and
relieved only by
taking
in
analgesics.
OBJECTIVE DATA
Conscious,
coherent
Appears weak
Paleness noted
Grimacing
and
guarding of the
abdomen noted
S/P
(YUNG
SURGERY
PERFORMED
SA
KANYA), ____ day.
With
surgical
incision
at
(location/landmark
),
approximately
_____
inches
in
length; no signs of
infection noted.
With vital signs of
(dapat
elevated
ang
pulse
at
respirations,
pakilagyan
na
lang)

elevated
pulse,
respirations, and report
of 8/10 abdominal pain)

patient will have an

improved condition
as manifested by a
decrease
in
the
patients
pain
rating from 7 to 35, and absence of
non verbal cues of
pain
(grimacing,
guarding,
and
crying.)
LONG TERM GOAL
After 24 hours of
nursing
interventions,
the
patient will have an
improved condition
as manifested by a
pain rating of 0/10
and the absence of
both verbal and
non verbal cues of
pain, as well as
having vital signs
that are in normal
range.

include
location,
characteristics,
onset,
duration,
frequency, quality,
intensity
or
severity,
and
precipitating factors
of pain.
Assess GI status to
include abdominal
girth, bowel sounds

Assess incision site

Position
patient
comfortably

Create
a
quiet,
nondisruptive
environment
with
dim
lights
and
comfortable
temperature when
possible.
Aseptically
dress
the
incision
site
regularly
Encourage
to
increase fluid intake
Elicit behaviors that
are conditioned to

experience
and
must be described
by the client in
order
to
plan
effective treatment

To determine the
nature
of
the
condition as well
as to assess for
post
operative
complications that
may cause the
patients pain.
To note for post
operative
complications
Comfort
helps
reduce
skeletal
muscle
tension,
which will reduce
the intensity of the
pain
Comfort
and
a
quiet atmosphere
promote a relaxed
feeling and permit
the client to focus
on the relaxation
technique
rather
than
external
distraction.
To promote healing
and
prevent
infection.

produce relaxation,
such
as
deep
breathing, yawning,
abdominal
breathing,
or
peaceful imaging.
Advise
to
do
splinting when the
patient coughs or
sneezes
Reinforce
importance
of
proper nutrition

Instruct the patient

to
ambulate
as
tolerated
Instruct not to lift
heavy objects or
perform strenuous
activities

The
use
of
noninvasive
pain
relief
measures
can increase the
release
of
endorphins
and
enhance
the
therapeutic effects
of
pain
relief
medications.
Splinting prevents
dehiscence of the
surgical incision
Complete nutrition
promotes growth
of healthy cells,
hence,
faster
wound healing
Early
ambulation
post
operatively
prevents
tissue
adhesion
To prevent post
operative
complications;
dehiscence
of
surgical incision