Nursing process

Assessment Nursing diagnosis Goal Interventions Outcome

Bulging at hernia Risk of ineffective Complications will Watch for and There is no signs
site tissue perfusion be avoided next 24 immediately of complications
related to hernia hours report signs of within 24 hours
and the possibility incarceration and
of obstruction and strangulation
strangulation
 Nursing process
Assessment Nursing diagnosis Goal Interventions Outcome
Patient is Acute pain relate The patient will - Watch for and Pain was relieved
complaining of to swelling and express feelings immediately from 5 to 2 on
pan 5 on score pressure of comfort. report signs of score
incarceration and
strangulation.
- Administer I.V.
fluids and
analgesics for
pain as ordered.
- Place the patient
in
Trendelenburg's
position to
reduce pressure
on the hernia site
 Nursing process
Assessment Nursing diagnosis Goal Interventions Outcome
patient said that Risk of aspiration Client will be able - Instruct to take Patient has no
he often have oral related to reflux of to state the steps small frequent episodes of oral
regurgitation after gastric content in preventing meals regurgitation after
meals aspiration after 2 - Encourage not 2 hours of
hours of nursing to take meal 2 interventions
interventions hours before
bed time
 Nursing process
Assessment Nursing diagnosis Goal Interventions Outcome
Patient has Fear and anxiety Pt to be free from - explain the Pt is relieved of
repeated doubts related to anxiety with 2 procedure to fear and anxiety as
regarding surgery hospitalization hours of the patient in he state it.
interventions simple terms
- introduce the
patient to
similar patients
who had
undergone the
surgery