Assessment Nursing Diagnosis Planning Intervention Evaluation

Acute pain After 8 hours of Independent: After 8º of

Subjective: secondary to the rendering nursing 1. Evaluate pain rendering nursing
The patient surgical intervention, the regularly, noting care, the goals
verbalizes: “I felt procedure patient will be characteristics were met
pain on my (hysterectomy) as able to: - and location partially, as
surgical incision” evidenced by Decrease pain intensity (0-10). evidenced by: -
reported scale of 8 to 4 as 2. Identify specific Decreased pain
Objective: discomfort with a evidenced by activity scale to the level
- Reported pain pain scale of 8 stable vital signs. limitations. of 5.
with the pain (pain scale from 1 3. Reposition as
scaleof 8 (pain – 10), limited indicated.
scale from 1– 10) range of motion, 4. Encourage
- Facial Grimacing and sleep relaxation
- Guarding disturbance techniques like a
behavior pattern. deep breathing
exercise.
5. Monitor vital
signs

DEPENDENT:
1. Administer
analgesic
medication:
Ketorolac IVTT x 4
doses q 8 hours as
prescribed by the
physician.

Assessment Nursing Diagnosis Planning Intervention Evaluation

Subjective Hyperthermia After 30 min. of 1. Render TSB After 30 min. of
related to trauma nursing 2. Fluid intake nursing
“kanina pa po siya is manifested by intervention, the 3. Removal of intervention, the
nilalagnat” as In body patient manifests excessive clotting body of the
verbalized by the temperature of Thermo regulating 4. Put a cold patient is able to
patient’s relative 39.4 C. as evidenced by: compress on the reach the normal
forehead, neck, range of body
Objective > T – > Skin axilla, and groin. temperature. >
39.4% C > Chilling temperature in 5. Every 5 the patient is able
> Clammy Skin > the expected minutes, check for to verbalize
Skin warm to range temperature if understanding of
touch the temperature techniques of
> Body is with in normal proper TSB.
temperature w/in range
normal limits 6. Teach the
proper TSB
> describes to techniques, like
 prevent or avoiding long
minimize inc. in strokes and only
body temp patting the wet
towel on the skin.
> describe proper
measures during
TSB

Assessment Nursing Diagnosis Planning Intervention Evaluation

Subjective Anxiety related to After continuous -encourage After continuous
change in Health nursing verbalization of nursing
“hindi ako status as intervention, the concerns intervention, the
mapalagay kasi manifested by client will be able client was able to:
baka hindi ako irritability. to: -Verbalize -assist patient in
gumaling appropriate range expressing -verbalized
agad.naaawa ako of feeling. feelings by active appropriate range
mga anak ko.”As listening of feelings.
verbalized by the
patient -provide accurate
and concrete
Objective information about
what is being
>Irritability done
>poor eye contact
-provide a calm
>Expressed and peaceful
concerns due to environment
change in life
events -encourage
>dry mouth relaxation
techniques

-encourage to
project a positive
and realistic
attitude