ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute Pain Short term: Independent: Independent: Short term:

“Ang sakit ng tahi related to Within 7-8 hours of 1. Facilitate deep 1. To decrease After 8 hours of
ko, hindi ako presence of nursing breathing exercise discomfort and nursing intervention,
makagalaw ng postoperative intervention, the facilitate relaxation. the patient was able
maayos” as surgical incision patient will verbalize 2. Reposition the patient to verbalize relief of
verbalized by the relief of pain as as indicated. 2. Prevents undue pain as evidenced by:
patient. evidence by: strain on operative • Pain scale
 Pain scale from 3. Encourage use of site that may relieve from 8/10 to 4/10
 P – during 8/10 to 4/10 relaxation techniques: pain and enhance • No facial
exertion and in  No facial  Deep-breathing circulation. grimace and guarding
moving grimace and exercises, guided behavior
 Q – sharp pain guarding imagery, 3. Relieves muscle and • Reported
 R – none behavior visualization, music. emotional tension; methods that provide
 S – 8/10  Verbalizes enhances sense of pain relief, by
 T – none methods that 4. Provide adequate rest control and may verbalizing,
provide pain periods, uninterrupted improve coping “Nababawasan yung
Objective: relief sleep and facilitate a abilities. sakit pag nagrerelax
 Difficulty in quiet and calm ako habang nakikinig
moving Long term: environment 4. Sleep deprivation sa radio”.
 Facial Grimace Within 3-4 days of can increase
proper nursing 5. Provide additional perception of pain. Long term:
 Restlessness comfort measures:
intervention, the To avoid any pain After 3 days of proper
 Guarding backrub, heat or cold
patient will verbalize stimulants, to keep nursing intervention,
behavior on the applications. the patient's rest the patient was able
affected area
 Absence of pain from any disruption to verbalize, “Wala na
 Vital signs 6. Raise the side rails
in exertion and and conserves akong masyadong
taken as and lower the bed at sakit na
in moving. energy for healing.
follows: all times. nararamdaman pag
 BP: 130/90 humihinga ako at pag
5. Improves circulation,
mmHg Dependent: gumagalaw-galaw”
reduces muscle
 PR: 92 bpm
tension and anxiety
 RR: 22 cpm 1. Administer medication GOAL MET.
associated with pain.
 T: 37.4°C as ordered.
Enhances sense of
 O2 sat: 97% well-being.

6. Helps ensure the

 patient’s safety

Dependent:
1. Necessary to relieve
mild or moderate
postoperative pain.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired skin Within 7-8 hours of Independent: Independent: After 8 hours of
“Ang tagal integrity related to nursing 1. Use pillows or foam 1. These measures nursing interventions,
gumaling ng tahi surgical interventions, the wedges to keep bony reduce shearing the patient was able
ko” As verbalized procedure as patient will: prominences from forces on the skin. to:
by the patient. manifested by  Manifest no direct contact with 2. Aseptic technique • Manifest no
sutured wound. signs of each other. Keep eliminates all the signs of inflammation
Objective: inflammation pillows under the heels chances of getting and bleeding on the
 Presence of and bleeding on to raise off bed. infection. suture site.
sutured wound the suture site. 2. Perform wound care 3. Educating patients • Verbalize and
from surgical  Verbalize and and dressing and caregivers demonstrate proper
procedure. demonstrate aseptically. methods to maintain wound care,
 Dry intact proper wound 3. Educate patients and skin integrity aseptically.
wound dressing care aseptically caregivers about enhances their • Report pain
without  Report pain proper skin care. sense of self-efficacy has lessened and no
presence of lessened and no 4. Encourage adequate and prevents skin signs of tenderness in
bleeding signs of nutrition and hydration: breakdown. surrounding area of
 Pain and tenderness in  2000 to 3000 4. Optimal wound suture site.
tenderness on surrounding kcal/day (more if healing requires
surrounding of area of suture increased metabolic adequate nutrition. GOAL MET.
suture site site. demands) Nutrition deficiencies
 Vital signs  Fluid intake of 2000 impede the normal
taken as mL/day unless processes that allow
follows: medically restricted. progression through
 BP: 130/90 5. Reinforce the stages of wound
mmHg importance of turning, healing. 
 PR: 92 bpm mobility, and 5. These will enhance
 RR: 22 cpm ambulation. their sense of
 T: 37.4°C 6. Raise the side rails efficacy and can
and lower the bed at improve compliance
 O2 sat: 97%
all times. with the prescribed
interventions.
Dependent: 6. Helps ensure the
1. Administer medication patient’s safety
as ordered.
2. Administer IVF PNSS Dependent:
1. Necessary to relieve
mild or moderate
postoperative pain.
2. To restore and
 replace body fluid
loses

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient Within 1-2 hours Independent: Independent: After 2 hours of
“Ilang beses na Knowledge of nursing 1. Review and have 1. Promotes competent nursing
ako related to lack of information, patient or SO self-care and information,
naoperahan, recall and patient will be able demonstrate dressing enhances patient was able
pero di ko pa information to: or wound and tube care independence. to:
din alam ano misinterpretation.  Verbalize when indicated. Identify 2. Reduces potential • Verbalize
ang aking understanding source for supplies. for acquired understanding of
gagawin” As of condition, 2. Review avoidance of infections. condition, effects
verbalized by effects of environmental risk 3. Prevents undue of procedure and
the patient. procedure and factors: exposure to strain on suture site. potential
potential crowds or persons with 4. Provides elements complications.
Objective: complications. infections. necessary for tissue • Verbalize
 Ask several  Verbalize 3. Identify specific activity regeneration or understanding of
questions understanding limitations. healing and support therapeutic needs.
and request of therapeutic 4. Review importance of of tissue perfusion • Correctly
for more needs. nutritious diet and and organ function. perform necessary
information.  Correctly adequate fluid intake. 5. Promotes return of procedures and
 Facial perform 5. Recommend planned normal function and explain reasons
expression necessary or progressive exercise enhances feelings of for actions.
shows fear procedures and Schedule adequate general well-being. • Initiate
and and explain rest periods. Prevents fatigue and necessary lifestyle
confused. reasons for 6. Discuss drug therapy, conserves energy for changes and
 Vital signs actions. including use of healing. participate in
taken as  Initiate prescribed and OTC 6. Enhances treatment
follows: necessary analgesics. cooperation with regimen.
 BP: 130/90 lifestyle 7. Include SO in teaching regimen; reduces
mmHg changes and program or discharge risk of adverse GOAL MET.
 PR: 92 bpm participate in planning. Provide reactions and/or
 RR: 22 cpm treatment written instructions untoward effects.
 T: 37.4°C regimen. and/or teaching 7. Provides additional
 O2 sat: 97% materials. Instruct in resources for
use of and arrange for reference after
 special equipment. discharge. Promotes
effective self-care.

Dependent: Dependent:
1. Review specific surgery 1. Provides knowledge
performed, and base from which
procedure done, and patient can make
future expectations informed choices.
relayed by the 2. Monitors progress of
physician. healing and
2. Stress necessity of evaluates
follow-up visits with effectiveness of
providers, including regimen.
therapists, laboratory.