SILLIMAN UNIVERSITY

COLLEGE OF NURSING
DUMAGUETE CITY
S.Y. 2021 - 2022

NCM 54 - RLE - OR ROTATION

NURSING CARE PLAN

TOTAL ABDOMINAL HYSTERECTOMY AND BILATERAL
SALPINGO-OOPHORECTOMY

Submitted to:
Asst. Prof. Veveca V. Bustamante R.N. M.N

Submitted by:
Doria, Chriselle Janeane U.
Faburada, Jazzie Lace O.
Garganian, Ma. Therese H.
BSN III - D3

MAY 26, 2022

Clinical Instructor: Asst. Prof. Veveca V. Bustamante R.N., M.N
Student Circulating Nurse: Ma. Therese H. Garganian
Student Scrub Nurse #1: Jazzie Lace O. Faburada
Student Scrub Nurse #2: Chriselle Janeane U. Doria

I. OVERVIEW

Patient’s Name: Colina, Genevieve R. Case No.: 67982 Birthdate: February 28, 1971 Gender: F Age: 51
Address: Villa Allegre, Tanjay City, Neg. Or.
Admitting Diagnosis: AUB SECTO UTERINE ADHESIOLYSIS, MYOMA ENDOMETRIAL PATHOLOGY S/P DIAGNOSTIC CURETTAGE ENDOMETRIOTIC CYST
Post Diagnosis: Class I modified Goldman’s classification low (1-2%)

II. SURGICAL TEAM & OPERATION

Operation: Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) Date: May 26,2022
Surgeon: Dr. Somoza Time started: 9:12 AM
Anesthesiologist: Dr. Delwin Nuique Time ended: 11:13
Anesthesia: Subarachnoid Spinal Block (SAB)
OR Scrub Nurse: Rey Pis-an
OR Circulating Nurse: Louie Pileo
 NURSE’S NOTES

TIME REMARKS

8:50 A.M ● Wheeled to operating room

● Transferred to the OR table, positioned supine.
● Administered oxygen via nasal cannula at 2 Lpm.
● Attached to monitor with vital signs obtained: PR: 84bpm RR: 19cpm BP: 120/80 O2Sat: 99%.
● Checked drainage bag of foley catheter
- Urine: 200 cc, light yellow
● Assessed patient
- Patient awake and sweating
- At left metacarpal vein: PLR 850 ml
- At right metacarpal vein: PNSS 750 ml

9:00 A.M ● Checked patient vitals (based on monitor)

- ECG: 64
- PR: 64 bpm
- BP: 102/64 mmHg
- RR: 20 cpm
- SpO2: 99%
● Induction of Subarachnoid (spinal) block administered by Dr. Delwin Nuique
● Assessed patient
- Able to assume correct position (left-lateral position) for anesthesia insertion
- Nasal cannula in place

9:05 A.M ● Skin preparation on surgical site done by OR circulating nurse

● Counting of instruments
○ 8 - straight
○ 8 - curve
○ 3 - allis
○ 3 - bobcocks
 ○ 2 - needle holders
○ 2 - tissue forceps with teeth
○ 1- tissue forcep without teeth
○ 1 - mayo scissors
○ 2 - scalpel
○ 4 - towel clips
○ 5 - packs
○ 7 - sutures
○ 1- metzenbaum
○ Additional instruments:
○ 1 - liver
○ 1- deaver
○ 1- malleable retractor
○ 2 - army navy
○ 2 - richardson retractors

9:10 A.M ● Prayer

● Introduced surgical team
● Checked patient vitals (based on monitor)
- ECG: 64
- PR: 62 bpm
- BP: 94/55 mmHg
- RR: 20 cpm
- SpO2: 99%

9:12 A.M ● Surgery started

● Assessed patient: Unconscious
● Checked patient vitals (based on monitor)
- ECG: 63
- PR: 63 bpm
- BP: 105/64 mmHg
- RR: 24 cpm
 - SpO2: 96%

9:15 ● Cauterized, patient was unconscious.

9:20 ● Checked patient vitals (based on monitor)

- ECG: 67
- PR: 67 bpm
- BP: 91/59 mmHg
- RR: 23 cpm
- SpO2: 97%

9:21 ● Suctioned

9:25 ● Administered additional IV bottle PLR 1L

● Packs-in=2
● Checked patient vitals (based on monitor)
- ECG: 66
- PR: 66 bpm
- BP: 85/47 mmHg
- RR: 23 cpm
- SpO2: 96%

9:30 ● Assessed patient: half-awake (eyes were slightly opened) then closes after a couple of seconds, was shivering (chills), nasal
cannula in place.

9:40 ● Suctioned blood

● Checked patient vitals (based on monitor)
- ECG: 68
- PR: 67 bpm
- BP: 100/64 mmHg
- RR: 20 cpm
- SpO2: 98%

9:50 ● Checked patient vitals (based on monitor)

 - ECG: 64
- PR: 64 bpm
- BP: 91/61 mmHg
- RR: 18 cpm
- SpO2: 98%

10:00 ● Half-awake then closes eyes

● Suctioned and cauterized
● Checked patient vitals (based on monitor)
- ECG: 64
- PR: 65 bpm
- BP: 88/65 mmHg
- RR: 19 cpm
- SpO2: 98%

10:06 ● Specimen out

● Checked patient vitals (based on monitor)
- ECG: 64
- PR: 65 bpm
- BP: 88/65 mmHg
- RR: 19 cpm
- SpO2: 98%

10:15 ● Suturing
● Checked patient vitals (based on monitor)
- ECG: 63
- PR: 63 bpm
- BP: 110/85 mmHg
- RR: 14 cpm
- SpO2: 99%

10:30 ● Suturing
● Checked patient vitals (based on monitor)
 - ECG: 70
- PR: 69 bpm
- BP: 120/63 mmHg
- RR: 12 cpm
- SpO2: 100%

10:40 ● Cauterized & suctioned

● Checked patient vitals (based on monitor)
- ECG: 70
- PR: 69 bpm
- BP: 120/63 mmHg
- RR: 12 cpm
- SpO2: 100%

10:45 ● 2 packs down

● Initial counting of instruments:
○ 8 - straight
○ 8 - curve
○ 3 - allis
○ 3 - bobcocks
○ 2 - needle holders
○ 2 - tissue forceps with teeth
○ 1- tissue forcep without teeth
○ 1 - mayo scissors
○ 2 - scalpel
○ 4 - towel clips
○ 5 - packs
○ 7 - sutures
○ 1- metzenbaum
○ Additional instruments:
○ 1 - liver
○ 1- deaver
○ 1- malleable retractor
 ○ 2 - army navy
○ 2 - richardson retractors

10:49 ● Initial counting of packs, needles, sutures, instruments counted and complete.

10:55 ● Cauterized & suctioned

● Assessed patient: shaking, opened eyes then closes after a minute
● Checked patient vitals (based on monitor)
- ECG: 76
- PR: 67 bpm
- BP: 108/73 mmHg
- RR: 16 cpm
- SpO2: 100%

10:56 ● Final counting of instruments:

○ 8 - straight
○ 8 - curve
○ 3 - allis
○ 3 - bobcocks
○ 2 - needle holders
○ 2 - tissue forceps with teeth
○ 1- tissue forcep without teeth
○ 1 - mayo scissors
○ 2 - scalpel
○ 4 - towel clips
○ 5 - packs
○ 7 - sutures
○ 1- metzenbaum
○ Additional instruments:
○ 1 - liver
○ 1- deaver
○ 1- malleable retractor
○ 2 - army navy
 ○ 2 - richardson retractors

11:00 ● Final counting of packs, needles, sutures, instruments counted and complete.

11:03 ● Washing inside the field

● Added 1 pack

11:05 ● Started closing

● Assessed patient: shivering

11:13 ● Ended operation

● Checked patient vitals (based on monitor)
- ECG: 76
- PR: 67 bpm
- BP: 110/95 mmHg
- RR: 17 cpm
- SpO2: 100%
● Measured urine 100 cc, light yellow

11:20 ● Suturing done, dressing applied on incision.

● Informed patient surgery was done. Cleaned patient. After care of instruments used and the operating room.

11:30 ● Out in the OR

11:35 ● Entered and transferred to PACU

● Administered oxygen via nasal cannula at 2 L/min.
● Attached to monitor with vital signs obtained:
○ T: 36.1 ºC
○ PR: 64 bpm
○ RR: 23 cpm
○ BP: 113/67
 ○ O2Sat: 99%.

11:45 ● Patient sleeping. Chills noted due to anesthesia wearing off.

● Checked patient vitals (based on monitor)
- T: 36.1 ºC
- PR: 64 bpm
- BP: 128/61 mmHg
- RR: 23 cpm
- SpO2: 99 %

12:00 ● No signs of bleeding from the incision site in the dressing.

● Urine checked, light yellow with no blood
● Checked patient vitals (based on monitor)
- T: 36.1 ºC
- PR: 64 bpm
- BP: 128/61 mmHg
- RR: 23 cpm
- SpO2: 99 %

12:15 ● Checked patient vitals (based on monitor)

- T: 36.1 ºC
- PR: 64 bpm
- BP: 133/64 mmHg
- RR: 23 cpm
- SpO2: 99 %

12:30 ● Checked patient vitals (based on monitor)

- T: 36.5 ºC
- PR: 62 bpm
- BP: 131/71 mmHg
- RR: 18 cpm
- SpO2: 100 %
12:45 ● Emptied urine 200 cc, light yellow with no blood
● Checked patient vitals (based on monitor)
- T: 36.5 ºC
- PR: 64 bpm
- BP: 123/64 mmHg
- RR: 20 cpm
- SpO2: 100 %

1:00 ● Pt is awake and responsive. Rated pain as 5 out of 10; 0 as no pain 10 as most painful.
● Checked patient vitals (based on monitor)
- T: 36.2 ºC
- PR: 66 bpm
- BP: 124/67 mmHg
- RR: 21 cpm
- SpO2: 100 %

1:10 ● Checked patient vitals (based on monitor)

- T: 36.1 ºC
- PR: 68 bpm
- BP: 122/67 mmHg
- RR: 20 cpm
- SpO2: 100 %
● Administered pain reliever (Tramadol) by PACU nurse
● Tubes are patent and free from obstruction. No bleeding in the dressing noted.
● End of duty.
 PREOPERATIVE PHASE

CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Knowledge Deficit r/t During my 1-hr care, the 1. Review the effects
● Verbalized “Di unfamiliarity of the patient will be able to gain
gyapon ko sure surgical procedure knowledge as evidenced
unsay mahitabo (TABHSO) by:
aning sa ako ● Asks questions
procedure” related to the
procedure
Objective: ● Verbalizes
● Does not maintain understanding of
eye contact indications for
● Does not interact TABHSO and
postoperative
expectations
● Verbalized feeling 2. Discuss the
of preparedness for
the procedure
● Participates in
necessary
procedures taken
pre operatively
● Able to maintain
eye contact and
interact
1. Provides After my 1-hr care, the
of surgical knowledge base goal was partially met as
procedure and from which patient evidenced by:
future expectations. can make informed
The patient needs to choices. ● Pt asked questions
know that she will regarding the
no longer procedure
menstruate or bear ● Verbalized feeling
children, and the of preparedness for
possible need for the procedure
hormonal ● Participates in
replacement. necessary
procedures taken
2. Physical, pre operatively
complexity of emotional, and ● No eye contact and
problems social factors can interaction noted
anticipated during have a cumulative
recovery: emotional effect, which may
lability and delay recovery,
expectation of especially if the
feelings of hysterectomy was
depression and/or performed because
sadness; excessive of cancer. Providing
fatigue, sleep an opportunity for
disturbances, problem-solving
urinary problems. may facilitate the
process.

3. Discuss the 3. Patient can expect

 resumption of to feel tired when
activity. Encourage she goes home and
patient to do light needs to plan a
activities initially, gradual resumption
with frequent rest of activities, with
periods and the return to work
increasing activities an individual
or exercise as matter. Prevents
tolerated. Stress excessive fatigue;
importance of conserves energy
individual response for healing and
in recuperation. tissue regeneration.

4. Identify individual 4. Strenuous activity

restrictions: intensifies fatigue
avoiding heavy and may delay
lifting and healing. Activities
strenuous activities, that increase
prolonged sitting or intra-abdominal
driving. Avoid tub pressure can strain
baths and douching surgical repairs, and
until physician prolonged sitting
allows. potentiates the risk
of thrombus
formation. Showers
are permitted, but
tub baths and
douching may
cause vaginal or
incisional infections
and are a safety
hazard.
5. Review 5. When sexual
recommendations activity is cleared
of resumption of by the physician, it
sexual intercourse. is best to resume
activity easily and
gently, expressing
sexual feelings in
other ways or using
alternative coital
positions.

6. Encourage taking 6. Taking hormones

the prescribed with meals
drug(s) routinely establishes a routine
for taking the drug
and reduces the
potential for initial
nausea.

7. Discuss potential 7. Development of

side effects: weight some side effects is
gain, increased skin expected but may
pigmentation or require
acne, breast problem-solving
tenderness, such as a change in
headaches, dosage or use of
photosensitivity. sunscreen.

8. Review incisional 8. Facilitates

care when competent self-care,
appropriate. promoting
independence.

CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES
Subjective: Anxiety r/t change in Within our 1-hr of care, the
● Verbalized health status client will be able to
“Nakuyawan ko manage anxiety as
maam” evidenced by:
1. Appear at ease
Objective: 2. Acknowledge and
● Diagnosed with discuss fears and
cervical myoma concerns.
● 3. Verbalize
awareness of
feelings of anxiety
4. Report anxiety is
reduced to a
manageable level.
5. Demonstrate coping
9. Identify signs and 9. Early recognition
symptoms requiring and treatment of
medical evaluation, developing
fever/chills, change complications such
in character of as infection and
vaginal or wound hemorrhage may
drainage; bright prevent
bleeding. life-threatening
situations.
Hemorrhage may
occur as late as 2
wk postoperatively.
INTERVENTIONS RATIONALE EVALUATION
1. Recognize 1. Since a cause of After 8 hours of nursing
awareness of the anxiety cannot care, the goal was fully
patient’s anxiety. always be met, the patient managed
identified, the her anxiety, as evidenced
patient may feel as by:
though the feelings 1. Appeared at ease
being experienced 2. Acknowledged and
are counterfeit. discussed fears and
Acknowledgment concerns
of the patient’s 3. Verbalized
feelings validates awareness of
the feelings and feeling of anxiety
communicates 4. Reported anxiety
acceptance of those was reduced to a
feelings. manageable level
behaviors that 5. Demonstrated use
reduce anxiety 2. Use presence, touch 2. Being supportive of deep breathing
(with permission), and approachable exercises and
verbalization, and promotes relaxation
demeanor to remind communication. techniques
patients that they
are not alone and to
encourage
expression or
clarification of
needs, concerns,
unknowns, and
questions.

3. Familiarize patient 3. Awareness of the

with the environment
environment and promotes comfort
new experiences or and may decrease
people as needed. anxiety experienced
by the patient.
Anxiety may
intensify to a panic
level if patient feels
threatened and
unable to control
environmental
stimuli.

4. Interact with patient 4. The nurse or health

in a peaceful care provider can
manner. transmit his or her
own anxiety to the
hypersensitive
 patient. The
patient’s feeling of
stability increases
in a calm and
non-threatening
environment.

5. Accept patient’s 5. If defenses are not

defenses; do not threatened, the
dare, argue, or patient may feel
debate. secure and
protected enough to
look at behavior.

6. Converse using a 6. When experiencing

simple language moderate to severe
and brief anxiety, patients
statements. may be unable to
understand
anything more than
simple, clear, and
brief instruction.

7. Lessen sensory 7. Anxiety may

stimuli by keeping intensify to a panic
a quiet and peaceful state with excessive
environment; keep conversation, noise,
“threatening” and equipment
equipment out of around the patient.
sight. increasing anxiety
may become
frightening to the
patient and others.
 8. If the situational 8. Anxiety is a normal
response is rational, response to actual
use empathy to or perceived
encourage patient to danger.
interpret the anxiety
symptoms as
normal.

9. Intervene when 9. Anxiety is a normal

possible to response to actual
eliminate sources of or perceived
anxiety. danger; if the threat
is eliminated, the
response will stop.

CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Altered Comfort: Acute Within our 1-hr of care, the 1. Review the pain 1. Identify needs and After our 1-hr of care, the
● Verbalized “naay pain r/t intrauterine tissue client will be able to scale. appropriate goal was partially met as
sakit gamay” damage manage pain as evidenced interventions. evidenced by:
● Rated pain as 2 out by:
of 10; 0 as no pain, 2. Encourage clients 2. To divert the 1. Verbalization of
10 as most painful 1. Verbalization of to use relaxation attention of the reduction of pain
reduction of pain techniques and pain mother and the pain 2. Rated pain as 2 out
Objective: 2. Reduced pain; rate distraction. that is felt. of 10; 0 as no pain,
● Grimace pain as 0-1 out of 10 as most painful
● Sighing 10; 0 as no pain, 10 3. Motivation: for 3. Accelerating 3. Felt a tille tingling,
as most painful mobilization as involution and as claimed, during
3. Do not feel pain indicated. reducing the pain mobilization
 during gradually. 4. Vital signs within
mobilization, normal limits.
4. Vital signs within 4. Encourage clients 4. Reduce pain.
normal limits. to rest.

5. Collaboration: 5. Loosening the

providing analgesic peripheral nervous
system to decrease
pain.
 INTRAOPERATIVE PHASE

CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Objective Data: Risk for Injury related to Within my 6 hours of care, INDEPENDENT: INDEPENDENT: At the end of our 6 hour
anesthesia and the patient will be free care, the goals have been
● Undergoing total intraoperative surgical from injury as evidenced ● Monitor vital signs ● Alteration in the partially met as evidenced
abdominal procedure (TAHBSO) by: every 5 minutes patient’s vitals by:
hysterectomy and (respirations, blood indicate problems
bilateral ● Present no pressure, pulse) or possible ● Presented no
salpingo-oophorect unexpected threats complications unexpected threats
omy to safety to safety. The
(positioned safely, ● Ensure patient ● To prevent patient was
● Low transverse monitoring devices safety by checking accidents like positioned properly,
incision done on are placed properly) if safety straps are falling off the monitoring devices
hypogastric are of intact and patient is surgical bed. are also properly
the abdomen ● Present stable vital positioned properly Improper placed.
signs positioning of the
● Client is under patient’s body can ● Vitals: (based on
spinal anesthesia ● Free from any cause serious injury monitor)
(subarachnoid complications or or paralysis BP: 88/65 mmHg
spinal block) possible adverse PR: 65 bpm
effects of anesthesia RR: 19 cpm
● Vitals: (based on and surgical ● Always check OR ● To prevent SpO2: 98%
monitor) procedure environment for accidents like
BP: 94/55 mmHg any safety hazards electrocution or ● Remained from any
PR: 62 bpm including electrical cross-contamination complications or
RR: 20 cpm hazards or presence possible side effects
SpO2: 99% of contaminants of anesthesia and
(blood, urine or surgical procedure
dust)

● Make sure needed ● Faulty equipment

 eqipment is can cause delay of
obtained, prepared, the operation and
or set up in working harm the patient
order including the
suction machine,
monitoring devices,
IV lines, and foley
bag catheters.

● Make sure needed ● To prevent delays

or assistive devices or errors from
are within reach occuring which
may result to
injuries

● Provide other safety ● To prevent any

measures such as physical injuries.
properly removing Draping exposed
excess antiseptic areas reduces risk
solution from the for hypothermia
patient’s skin or
immediately drape
exposed areas after
setting up sterile
field

CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Objective Data: Risk for Infection related Within my 6 hours of care, INDEPENDENT: INDEPENDENT: At the end of our 6 hour
to surgical procedure the patient will be free care, the goals have been
● Vitals: (based on (TAHBSO) from infection as ● Monitor vital signs ● Alteration in the partially met as evidenced
monitor) evidenced by: every 5 minutes patients vitals by:
PR: 62 bpm (pulse, respirations, especially a high
RR: 20 cpm ● Present stable vital blood pressure, and temperature (fever), ● Vitals: (based on
BP: 94/55 mmHg signs temperature if increased pulse or monitor)
SpO2: 99% possible) respiratory rate BP: 88/65 mmHg
● Show no signs of indicate presence of PR: 65 bpm
● Undergoing total complications infection RR: 19 cpm
abdominal brought by SpO2: 98%
hysterectomy and infection such as an ● Maintain sterility ● TAHBSO is an
bilateral elevated by avoiding having invasive procedure ● Showed no signs of
salpingo-oophorect temperature, chills in contact with a where an incision is complications (no
omy or shivering, person, item or area made in the belly chills or shivering,
swelling or bloody that is considered button. It is a great no swelling or
● Low transverse drainage on surgical unsterile opportunity for bloody discharge on
incision done on incision site microorganisms to site)
hypogastric are of enter the body.
the abdomen ● Foley bag catheter Breaking sterility ● Foley bag catheter
is free from kinks can result to is free from any
● Presence of foley or obstruction & infection and harm kinks and
bag catheter drained if needed the patient obstruction.
Drained when
● Urine ● Always wash hands ● Washing hands needed
characteristics do before and after between procedures
not indicate having in contact and wearing clean ● Urine is light
presence of with the patient or gloves reduces the yellow, 120 cc
infection (no odor, other possible risk of transmitting
do not appear contaminants microorganisms to
cloudy or dark in (catheters). Wear the patient and
color) clean gloves if acquiring them as
possible well

● Check foley bag ● A block can result

 catheter for any to kidney
kinks or infections. Properly
obstructions. Make placing the bag can
sure it is properly reduce accidents
placed and clean such as stepping on
the catheter bag.
And cleaning can
avoid introduction
of microorganisms

● Drain catheter if ● Cloudy or dark

necessary and note color urine and with
for urine odor indicates an
characeteristics infection

● Monitor the ● The following are

incision site for signs of infection
redness, swelling,
purulent discharge
or draining. Make
sure dressing is
intact

CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Objective Data: Risk for Deficient Fluid Within my 6 hours of care, INDEPENDENT: INDEPENDENT: At the end of our 6 hour
Volume related to active the patient will maintain care, the goals have been
● Vitals: (based on fluid loss (bleeding) and adequate fluid volume and ● Assess skin turgor, ● Tenting (poor skin partially met as evidenced
monitor) NPO status electrolyte balance as capillary refill, turgor), sluggish by:
BP: 94/55 mmHg evidenced by: mucous membranes capillary refill, dry
 PR: 62 bpm for signs of skin or dry, sticky ● Vitals: (based on
RR: 20 cpm ● Stable vital signs dehydration mucous membranes monitor)
SpO2: 99% (blood pressure, indicate deficient BP: 88/65 mmHg
pulse and fluid volume PR: 65 bpm
● 5 packs soaked with respiratory rate) RR: 19 cpm
blood during ● Monitor vital signs ● Common SpO2: 98%
operation ● A urine output every 5 minutes manifestations
greater than 30 (blood pressure, include a decreased ● Urine is light
● Patient on NPO ml/hr pulse and blood pressure, yellow, 120 cc
status prior to respiratory rate) weak thready
operation ● Present normal skin pulses, and ● Presented normal
turgor, capillary shortness of breath skin turgor,
refill, and mucous capillary refill, and
membranes mucous membranes

● Monitor urine ouput ● A urine output less

including color. than 30 ml per hour,
Report if less than concentrated urine
30 ml per hr for 2 inidcates deficient
consecutive hours fluid volume

● Monitor the patients ● It is indicated to

IV and obtain new prevent shock
one incase of
replacement

● Document mental ● Neurologic signs

status of the patient include decreased
level of
consciousness,
dizziness,
weakness, and
headache
 POSTOPERATIVE PHASE

CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Altered Comfort: Pain Within our 3 hour of care, Independent: At the end of our 3 hour of
● Verbalized,“nagngu related to abdominal the patient will be able to: care, the goals have been
tngut akong tahi surgical incision ● Monitor patients’ ● Increased blood partially met as evidenced
ma’am, sakit sya e secondary to TAHBSO vitals every 15 pressure, heart rate, by:
lihok” ● Vitals within minutes for first and respirations
Objective: normal range such hour indicate pain and ● Vital signs at 1:10
● Vital signs at 1:00 as BP 100-120/ discomfort P.M:
P.M: 60-80 mmHg, RR ○ T: 36.1 ºC
○ T: 36.2 ºC between 12-20 cpm ● Observe for ● Some patients’ are ○ PR: 68 bpm
○ PR: 66 bpm or PR between non-verbal cues of unable to verbally ○ BP: 122/67
○ BP: 124/67 60-100 bpm pain (limited communicate mmHg
mmHg movement, facial properly ○ RR: 20 cpm
○ RR: 21 cpm grimacing) ○ SpO2: 100
○ SpO2: 100 %
% ● Relaxed ● Be careful when ● To not further
appearance, no moving the patient worsen pain felt by ● Patient appeared
● Rated pain as 5 out longer creasing if cooperation is the patient slightly relaxed,
of 10; 0 as no pain brows, able to needed such as vital and slept after
10 as most painful. rest/sleep sign taking administered with
comfortably. pain reliever
● Patient squeezed ● Provide comfort ● To help soothe the (Tramdadol) by
her eyes shut when measure such as patient and reduce PACU nurse
little movement was ● Can tolerate pain appropriate touch or pain felt
done near when little caressing of skin ● Can still feel a little
abdominal area movement of body pain upon little
is made ● Instruct and ● Deep breathing movement of body
● Nodded when asked promote effective exercises are one of
if she was in pain. ● Verbalizes that the relaxation many ● Was not able to
pain has subsided to techniques such as non-pharmacologic verbalize if pain is
 a manageable level. deep breathing al interventions that reduced as she fell
can help ease asleep after being
discomfort/ pain administered with
pain reliever.
Dependent:
● Administer ● To help ease the
analgesics as pain felt by the
prescribed by patient
physician

CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for infection related Within our 6 hour of care, Independent: At the end of our 3 hour of
to surgical intervention the patient will be able to: care, the goals have been
Objective: and presents of foley ● Before coming into ● Washing hands partially met as evidenced
● Vital signs at 12:30 catheter contact with the between procedures by:
P.M: patient, make sure reduces the risk of
○ T: 36.5 ºC ● Vital signs within to wash your hands transmitting ● Vital signs at 12:45
○ PR: 62 bpm normal range such or practice hand bacteria to the P.M:
○ BP: 131/71 as having a hygiene. If there patient. Wearing ○ T: 36.5 ºC
mmHg temperature not isn't any water clean gloves can ○ PR: 64 bpm
○ RR: 18 cpm greater than 37.5 available, use also reduce the risk ○ BP: 123/64
○ SpO2: 100 degree celsius, alcohol. Wear of mmHg
% heart rate within gloves that are free transmitting/getting ○ RR: 20 cpm
60-100 bpm or of debris. bacteria ○ SpO2: 100
● Foley bag catheter respiratory rate %
in place within 12-20 cpm. ● Closely monitor ● Signs of infection
vital signs every 15 include an ● No signs of redness,
● Undergone ● Surgical incision minutes at the first increased swelling or
TAHBSO (Total site show no signs hour most temperature, pulse bleeding on surgical
 abdominal of infection such as especially the rate, and respiratory incision site upon
hysterectomy redness, swelling, temperature. rate assessment.
bilateral salpingo or bloody drainage.
oophorectomy) Gauze and tape are ● Any indications of ● The following signs ● No kinks or
procedure at 9:12 replaced with new redness, edema, mentioned indicate obstructions noted
AM ones. purulent discharge, infection on the on the catheter tube.
or bleeding at the surgical site Urine is
● Abdominal incision ● The Foley catheter incision site should freely-flowing.
covered with gauze bag is well taken be monitored. ● Blockage can result Catheter is also
and tape. care of. Catheter is in kidney properly positioned.
free of kinks or ● Check foley infections. Make
obstructions & catheter bag for any sure it cleaned daily ● Urine is light
replaced signs of to avoid introducing yellow in color with
immediately. obstructions or germs/bacteria no blood, 200 cc
kinks, make sure it inside the body amount noted upon
● Urine is properly placed which can cause monitoring at
characteristics does and clean infection PACU
not indicate
presence of ● Drain catheter bag ● Cloudy or dark
infection (not dark and check for urine urine color, and
or cloudy, no odor) characteristics such with odor might
as color and odor indicate presence of
infection.

CUES / EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for Ineffective Tissue Within our 3 hour of care, Independent: At the end of our 3 hour of
Perfusion r/t postoperative the patient will be able to: ● Monitor vital signs; ● Indicators of the care, the goals have been
Objective: tissue inflammation palpate peripheral adequacy of partially met as evidenced
● Vital signs at 12:00 secondary to TAHBSO pulses, and note systemic perfusion, by:
 P.M: capillary refill; fluid/blood needs,
○ T: 36.1 ºC ● demonstrate assess urinary and developing ● stable vital signs,
○ PR: 64 bpm adequate perfusion, output and complications. palpable pulses,
○ BP: 128/61 as evidenced by characteristics. good capillary
mmHg stable vital signs, refill, usual
○ RR: 23 cpm palpable pulses, ● Inspect dressings ● Proximity of large mentation,
○ SpO2: 99 % good capillary and perineal pads, blood vessels to the individually
refill, usual noting color, operative site adequate ­urinary
● Patient in supine mentation, amount, and odor of and/or potential for output.
position. individually drainage. Weigh alteration of
adequate ­urinary pads and compare clotting mechanism
● Oxygen via nasal output. with the dry weight increases the risk of
cannula in place. if the patient is postoperative
● show no signs of bleeding heavily. hemorrhage. ● free of edema
edema
● Avoid ● Creates vascular
● no evidence of high-Fowler’s stasis by increasing ● no signs of
thrombus position and pelvic congestion thrombus
development pressure under the and pooling of formation.
knees or crossing of blood in the
legs. extremities,
potentiating the risk
of thrombus
formation.

● Check for Homans’ ● May be indicative

signs. Note of the development
erythema, swelling of thrombophlebitis
of extremity, or or pulmonary
reports of sudden embolism.
chest pain with
dyspnea.