NURSING NURSING

ASSESSMENT PLANNING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

SUBJECTIVE: Risk for During 8 hours INDEPENDENT After 8 hours of

“ kaninang umaga infection related of nursing nursing
lang ako to surgical interventions, the Take and note vital To obtain baseline data interventions, the
naoperahan” intervention and client will remain signs. goal is met.
-verbalized by presence of free from
client urinary infection as Note risk factors to To help identify the The client remained
catheter. evidenced by occurrence of present risk factors that free from infection as
OBJECTIVE: normal vital infection in the may add up to the evidenced by normal
signs and incision site. infection. vital signs of:
Post-surgical absence of signs
wound and symptoms if T: 36.8 degrees
infection. Make health To help modify Celsius
Irritable teachings especially /change/avoid some of the
*Note signs and in identification of environmental factors PR: 98 bpm
Facial grimace symptoms of environmental risk present which could
infection: factors that could reduce the incidence of RR: 20 rpm
Restlessness add up on infection. infection.
- Fever BP: 120/80 mm/Hg
INFECTION - Chills &
sweat Practice proper hand Reduces risk of spreading O2 Sat: 98%
(-) T – Fever - Burning or washing. of bacteria.
(-) S – swelling pain when and there are no
(-) T –Tenderness urinating signs and symptoms
(-) R- Redness - Redness, of infection
soreness, presented.
or
swelling in
T: 36. 3 degree the
Celsius incision
site DEPENDENT
PR: 88 bpm - Diarrhea
- Vomiting Inspect incision and Provides for early
RR: 22 bpm dressing (note detection of developing
 characteristic of infectious process and
BP: 150/80 mm/Hg drainage from monitors resolution of
wound or drains and preexisting peritonitis.
O2 Sat: 97% presence of Suggestive of presence of
Normal VS: erythema. infection, developing
sepsis, abscess, and
T: 36.5-37 peritonitis.
degrees Celsius

PR: 60-100 bpm

RR: 16-20 rpm Administer Antibiotics will help kill and

antibiotics as stop the proliferation and
BP: 110-120/70- prescribed growth of the bacteria
80 mm/Hg which could cause
infection.
O2 Sat: 95-
100%

COLLABORATIVE

Maintain aseptic Regular wound dressing

technique when promotes fast healing and
changing dressing or drying of wound.
caring wound.

NURSING PLANNING NURSING RATIONALE EVALUATION

ASSESSMENT
DIAGNOSIS INTERVENTION

SUBJECTIVE: Acute pain After 10-20 INDEPENDENT After 20 minutes of

related to minutes of nursing
“Masakit ang part ng surgical nursing Take and note vital To obtain baseline data. interventions, the
pinag operahan” - as procedure as interventions, signs. goal is met.
verbalized by the manifested by the clients pain
client. irritability, facial will be lessen Assess pain, noting Helps evaluate degree The pain is lessen
 grimace, and the pain location, of discomfort and and the pain scale
restlessness, scale will characteristics, and effectiveness of subsided to 5 out of
OBJECTIVE: guarding subside to less intensity (0 to 10 or analgesia or may reveal 10.
behavior and a than or equal to similar coded scale). developing
- Weak in pain scale of 7 5 out of 10. complications. Surgical
appearance out of 10. causes for abdominal
pain usually subside
- Post-surgical gradually as healing
wound begins.

- Irritable

- Facial grimace Provide comfort Promoting relaxation

measures like enhances coping
- Restlessness helping the patient abilities
assume position of
- Guarding comfort. (semi
behavior fowlers position)
Suggest use of
- Pain scale: 7/10 relaxation technique
and deep breathing
exercises.
T: 36 degrees Celsius

PR: 88 bpm DEPENDENT This is the most

effective way to relieve
RR: 22 bpm Provide medications pain.
prescribed by the
BP: 150/80 mm/Hg attending physician

O2 Sat: 97%
 COLLABORATIVE
Regular wound
Maintain aseptic dressing promotes fast
technique when healing and drying of
changing wound.
dressing/caring
wound.

NURSING PLANNING NURSING RATIONALE EVALUATION

ASSESSMENT
DIAGNOSIS INTERVENTION

SUBJECTIVE: Impaired After 8 hours of INDEPENDENT After 8 hours of

physical Mobility nursing nursing
“ hindi ako maka kilos related to pain; interventions, Schedule activity or Activity and rest interventions, the
ng maayos - as prescribed client C will procedures with rest enhance healing and goal is met as
verbalized by the client movement exhibit periods. Encourage build muscle strength evidenced by:
participation in ADLs
restrictions tolerance and endurance. Client
within individual
evidenced by during physical limitations. participation promotes a Move within a range
OBJECTIVE: difficulty turning activity as sense of independence of motion
postural evidenced by a and control.
Limited range of instability normal Provide or assist with Increases strength
motion fluctuation of passive and active Strengthens muscles and function of
vital signs ROM and and promotes good affected body
Slowed movement during physical corestrengthening body mechanics
activity. exercises, depending
Reluctance to attempt on surgical Until healing occurs,
movement procedure. Assist activity is limited and
with activity or advanced slowly
Difficulty turning progressive according to individual
postural instability ambulation tolerance.

Review proper body

T: 36 degrees Celsius mechanics or Proper body mechanics
techniques for reduces the risk of
participation in
PR: 88 bpm muscle strain, injury to
activities.
the operative area, or
RR22 bpm pain. It also increases
client participation and
BP: 150/80 mm/Hg motivation in
progressive activity.
O2 Sat: 97% DEPENDENT:

Administer analgesic
medication as
prescribed by To relieve mild to
physician moderate pain