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Cues Nursing Long Term Short Intervention Rationale Evaluation/

Diagnosis Goal Term Goal Expected


Outcome
S A1 LG1 SG1 PDx E1
> “ Medyo NPI done. To establish
humahapdi Acute Pain To recognize The patient rapport with the Goal
itong tahi ko related to the will be able patient and Partially
sa dibdib at sa tissue physiological to verbalize promote good Met
tiyan” trauma responses of relief of communication. The patient
and reflex the body to thoracic was able to
>Pain of 4 in muscle disease (surgical) Assessed To determine verbalize
the thoracic spasm conditions. pain from 4 patient’s deviations from relief of
area, and 5 in secondary to 2 using general health normal and thoracic
the abd. area to surgery. Numeric condition. obtain (surgical)
using 0-10 Pain Scale subjective and pain from 4
Numeric Pain within the objectives cues. to 3 using
Scale. shift. Numeric
To monitor the Pain Scale
> (+) Increase SG1 Assessed pain level of pain within the
of pain on using numeric and for shift.
abd. area to 7 The patient pain scale. planning the
upon will be able intervention E2
ambulation to verbalize that will Goal
using 0-10 relief of alleviate pain. Partially
Numeric pain abdominal Monitored Met
scale. (surgical) vital signs. Provide The patient
pain from baseline data was able to
O 5-7 to 3 for changes in verbalize
>conscious, using patient’s relief of
coherent, Numeric condition. abdominal
oriented to Pain Scale PRx (surgical)
person, time within the Kept rested pain from
and place. shift. and Promotes 5-7 to 4
comfortable relaxation. using
>afebrile, with head of Allows proper Numeric
T=37.4oC bed elevated. ventilation and Pain Scale
improves lung within the
>(-) expansion. shift.
restlessness/ Provided
irritability safety by To avoid risks EO1
keeping the of falls that
> (-) SOB side rails up. could increase Patient will
the pain that the be able to
> Irregular patient understand
pulse rate of experience. the body’s
92 bpm Provided calm response to
restful Promotes disease
> BP = surroundings relaxation and conditions.
120/70mmHg and sleep.
minimized
environmental
> (+) activity or
tenderness on noise.
sternum
Administered
>(+) guarding analgesic To provide pain
behavior on medications relief.
chest area as ordered.

> (+) Wound


drsg. on PED
abdominal
area, (+) Encouraged
slight redness verbalization To be aware of
and of pain or the client’s
(-)purulent discomfort. level of
discharge of discomfort.
the surgical Advised
site. patient to Improves
perform deep pulmonary gas
breathing exchange and
exercises. for pain
management.
Encouraged
diversional To divert
activities. attention from
pain
Cues Nursing Long Term Short Intervention Rationale Evaluation/
Diagnosis Goal Term Goal Expected
Outcome
S> “Hindi pa A3 LG3 SG3 PDx E3
gaanong NPI done. To establish
naghihilom Risk for To maintain Will not rapport with the Goal Met
ang sugat ko” infection good manifest patient and
“Hindi pa related to a hygiene and signs of promote good Patient did
ako naliligo site for physical infection communication. not manifest
noon pa ng organism comfort. during the signs of
matapos ang invasion shift. Assessed To determine infection
operasyon” secondary patient’s deviations from during the
to heart condition. normal and shift.
O surgery. obtain
>afebrile, subjective and >afebrile,
T=37.4oC objectives cues. T= 37.1C

>(-) Monitored for To identify any


restlessness/ any developing EO3
irritability complications. infection for
early treatment Will be able
and referral. to maintain
> Poor good
hygiene Monitored Provide hygiene and
vital signs. baseline data physical
>(-) pallor for changes in comfort.
patient’s
>(-) condition.
headache,
dizziness Observed skin May predispose
for breaks, client to
>(-) Cough irritation, or infection.
and signs of
adventitious infection.
breath sounds
Monitored Fluctuation
>(+) guarding CTT for reflects
behavior on fluctuations. differences
chest area between
inspiration and
> good expiration.
capillary refill Excessive
less than 2 fluctuation may
seconds indicate airway
obstruction or
>S/P TVAP, presence of
MVR, PDA large
ligation pneumothorax.

> (+) Wound Checked To determine if


drsg. on dressing there is pus
abdominal frequently. formation or
area, (+) excessive
slight redness bleeding.
and (-)
purulent PRx
discharge of
the surgical Maintained To prevent
site. the wound bacterial
clean contamination
> (+) CTT of the wounded
insertion area

> (+) Patient kept Minimizes


incisional site safe and anxiety and
on sternum, comfortable. prevent injury.
with slight
redness and Provided Promotes
(-) purulent adequate rest. recovery from
discharge. surgery.
Administered May be given
antibiotic prophylactically
medications for suspected
as ordered. infection or
contamination.

PED

Advised to Helps avoid


change pulmonary
position every stasis of fluid
now and then that may lead to
respiratory
infection

Encouraged Reduces risk of


patient to infection.
maintain good
hygiene.

Encouraged to To meet the


verbalize needs of the
feelings and client.
needs.

Health Proper hygiene


teaching about is quite
proper necessarily to
hygiene. prevent any
accumulation of
bacteria
especially on
the open
wound.