ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS RATIONALE
S: “Masuol Pain Complex After 4 hours Monitor To have a After 4 hours
an akon related responses of of nursing vital signs. baseline of nursing
samad sa to tissue and nerve intervention, data. intervention,
may in Surgical endings due to the client’s the client’s
operahan” Incision trauma from reported pain Instruct the pain scale is
surgery will subside. client to To prevent decreased
O: >Pain (incision) and avoid bleeding of from 6 to 4.
scale: 6 cause strenuous the surgical
hypersensitivity exercise and incision made
>Facial to the central activities. from the
grimace nervous system operation.
> that causes
Protective unpleasant Instruct the
behavior physical and client to To promote
> Sighing emotional have a short blood
reactions and walk circulation
responses. everyday as and faster
a form of healing of
exercise or the incision.
ambulation

Advise the To aid in

client to strengthening
eat plenty of having a
of good Immune
nutritious system
foods and against
vegetables infection.
and drink
plenty of
water.
S: May Vulnerable to Educate the Monitor To have a The client
samad an Risk for invasion and patient on Vital signs baseline verbalized
akon tiyan Infection multiplication how to data. the ways in
kay gin CS of pathogenic prevent and preventing
ak” organism which reduce risk Wash hands It helps in infection.
may compromise for before and the
O: > health. infection. after prevention of
Visible patient pathogen
wound contact, transmission
dressing wear gloves between
in the when workers and
surgical necessary, patients.
site and
equipment
should not
be shared
with other
units.

Explain the This provides

importance awareness to
of hand the patient
hygiene and that
proper and handwashing
handwashing. and hand
hygiene
reduces the
transmission
of pathogens.

Demonstrate Patient gains

and explain more
the proper knowledge and
wound care skills in
reducing
infection.
S: Perceived lack Promote a Determine This will
“Naiilang Impaired of ease, relief sense of the type of help the
ak danay comfort and comfort after discomfort nurse to
didi isa transcendence in nursing that the provide
kuwarto physical, interventions client is solution to
kay damo psychospiritual, experiencing the problem
kami tas environmental, and let the as well as a
mairas cultural and patient rate baseline
ngan wara social it from 0- data.
electric dimensions. 10.
fan”
O: Review Increases the
Irritable knowledge client’s
mood, base and coping skills
moaning, coping
sighing skills that
have been
used
previously
to change
behavior or
promote
well-being.