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ASSESMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective airway After 30 minutes of  Position the patient in  Decreases pressure on the
clearance r\t, nursing intervention, SemiFowler. diaphragm and permits lung
 “nahihirapan akong tracheobronchial secretions the patient’s expansion
huminga at as manifested by increased
breathing pattern will
nangihihna po ako”, respiratory rate, wheezing  Instruct the patient for  Helps patient prolong
as verbalized by the sound and SaO2 of 91%, improve as
diaphragmatic pursed lip expiration time and decreases
patient. cough and presence of evidenced by breathing. air trapping.
mucus secretions normalization of
respiratory rate and
Objective: SaO2, and absence of  Encourage to conserve  Reduces metabolic and
adventitious breath strength by providing rest oxygen requirements.
 RR: 24 cpm periods and assisting with
sound
 Breath sound: activities.
wheezing on lung
fields.  Change position every two  Assists aeration and drainage
 SaO2: 91% hours. of all lobes of the lungs
 Cough and Mucus
secretions present  Encourage to take deep  Taking deep breaths will
breaths and to cough every reduce risk for atelectasis
hour. being a complication of post
operation.

 Administer oxygen at 2 liters  Facilitates oxygenation of the


per minute as ordered. body systems and prevent
hypoxemia and respiratory
distress.

 Perform bronchial tap/ Chest


 To loose secretions in the
Physiotherapy as ordered.
lungs

 Administer bronchodilator as
 To relieve
ordered.
bronchoconstriction and
wheezing.
Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective : Acute pain r/t After 30 mins of  Encourage deep breathing  Use a non-invasive pain relief
abdominal nursing exercises measures can increase release
 “Masakit tong incision intervention, patient of endorphins and enhance
inopera sakin” as therapeutic effects of
secondary to will report pain
verbalized medications
 Reports dull pain surgery relief from score of
5 to atleast 1 or 2  Instruct patient to splint  Splinting reduces tension on the
Objective: pain scale the incision with pillow surgical site and
and assist when reduces/prevents pain related
 Presence of repositioning or during movement
incision cut in the efforts to cough and deep
Left upper breathe
quadrant
 Encourage diversional  To distract attention
activities
 Reported pain
scale of 5/10  Assist to a comfortable  Frequent turning relieves
being 10 as the position every 2 hours pressure
most painful score
at the surgical site  Administer pain  To provide Pharmacologic
medication specifically treatment
 Muscle guarding Tramadol as ordered
Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Impaired physical Within 8 hours of  Ensure provision of  Good nutrition also gives
mobility r/t the shift, the nutritional needs as they required energy for participating
“Hirap ako generalized weakness patient will relate to mobility in an exercise
gumalaw mabuti secondary to surgery achieve optimal  Present safety  Promotes a safe, secure
kasi nanghihina environment by ensuring environment and may reduce
physical mobility
parin ako” as bed rails up, risk for falls/injury
by participating in
verbalized by the acitivities of daily  Position patient in semi-  Helps the patient to move
patient living and fowler to upright gradually from the lying position
 History of improvement of to the sitting position
range of motion  Keep supplies/personal  To conserve energy and prevent
sedentary
needed things within further injury
lifestyle noted reach
Objective:
 Assist patient in bed  To promote circulation, prevent
 Underwent exercises: arm, hands and deep vein thrombosis, and
fingers exercises, foot prepare for early ambulation
palliative
exercise, leg flexion and
surgery leg lifting, abdominal
 Age: 72 and gluteal contraction
(Decreased
muscle mass  Encourage and assist  Reduces incidence of
and strength) early ambulation postoperative compications
 Functional
 Encourage and assist  Assisting the patient in hygiene
Level Score: 2 patient to routine hygiene care not only gets the patient
(Requires help care as possible moving but helps restore a sense
from another of self-control and prepares the
person for patient for discharge.
assistance,
supervision, or  Encourage independence  Changes in mobility may lead to
teaching) in mobility and assist as a decrease in personal safety.
 Muscle strength needed by allowing Providing rest period conserves
grade: 3/5 ample time for activity, energy
providing rest period
after activity, and
reinforcing principles of
joint protection and work
simplification.
Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective : Ineffective  
tissue
 Family History of perfusion r/t
Hypertension noted
increased
 History of smoking
consuming half pack
per day for 21 years
 Reports dizziness and
weakness
 Upon interview, she
was on maintenance
(Medications) :
Amlodipine and
Losartan
Objective:
 Blood pressure:
160/110 mmHg
 12-Lead
electrocardiogram
revealed Sinus
tachycardia
 Presence of bilateral
1+ edema on lower
extremities
Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Sleep pattern After 15 mins. Of  Take Vital signs and  To minimize disturbance
disturbance r/t nursing monitor prior sleeping
“hindi ako discomfort intervention, the
makatulog ng  Encourage to eliminate  Stress interferes with person’s
secondary to client will employ
maayos ngayon stressful situations before ability to relax,rest and sleep
present illness techniques to bedtime
dahil sa kondisyon facilitate
ko” continuous sleep,  Perform actions to relieve  Facilitates induction of sleep
verbalize decreased discomfort such as
irritability on our repositioning deep
Objective: second day of shift. breathing, administering
prescribed analgesics
 Pale,
drawn,with  Discourage intake of  Caffeine is a stimulant for
dark circles foods and fluids high in wakefulness and alertness and
under eyes caffeine such as it will reduce total sleep time
 Frequent chocolate, coffee, tea
yawning
 Ensured appropriate  To conduce sleepig
sleeping environment

 Ensured noise to a
minimum and block out  Noise disrupts the transition
extraneous noise as from resting to sleeping
necessary

 Ensured bed linen  To aid in providing comfort


smooth, clean and dry