ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA:
“makirot nalang, siguro
dahil ito sa RELATED TO POST-
pagkakaopera ko”
verbalized by the patient
Pain scale 5/10
OBJECTIVE DATA:
S/P ExLap (3-13-23)
RUQ surgery site 11cm
(+) facial grimace
(+) guarding behavior in
surgery site
(+) discomfort
ALTERED Within the nurse’s shift, INDEPENDENT: After the nurse’s shift,
COMFORT the patient will:  Patient-Nurse  To establish rapport the patient:
 Be able to verbalize interaction  was able to
OPERATIVE comfort  Determine baseline  To track changes in verbalized comfort
PROCEDURE  Reduce pain scale vital signs condition  Reduced pain scale
from 5/10 to 3/10  Maintain flat on bed  Patient is post-op, to from 5/10 to 3/10
reduce the risk of (-) facial grimace
vomiting (-) guarding behavior
(-) discomfort
 Check incision site  To identify if the
for bleeding or doctor will prescribe
presence of antibiotics
infection and inform
physician.
 Monitor the  To check for the
patient’s pain efficacy of the
characteristics interventions
(intensity, location,
timeframe)

DEPENDENT:
 Administer  To relieve pain
analgesics as
ordered
 Administer  To treat infections
antibiotics if
ordered
 NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE DATA: ACTIVITY SHORT TERM  Teach the patient  Knowledge SHORT TERM:
“nahihirapan akong INTOLERANCE GOAL: and/or SO to promotes awareness
gumalaw galaw dahil sa RELATED TO Within 30 minutes of recognize signs of to prevent the  After 30 minutes of
operasyon ko” DECREASED nursing intervention, physical over complication of nursing intervention,
MOBILITY DUE TO patient will identify activity overexertion. patient identified
OBJECTIVE DATA: SURGERY methods/ techniques to methods/ techniques
 Limited mobility reduce activity  Deep-breathing  Promotes relaxation to reduce activity
 Weak in intolerance. exercises three or and coping abilities. intolerance.
appearance more times daily.  GOAL:MET
 Facial grimace LONG TERM GOAL:
when moving Within 2 days of  Established  Motivation and Long Term:
nursing intervention, the guidelines and goals cooperation are After 2 days of nursing
patient will report the of activity with the enhanced if the intervention, the patient
ability to perform patient and/or SO. patient participates reported ability to
required activities of in goal setting. perform required
daily living. activities of daily living.
 Promoted comfort  To enhance the  GOAL:
measures and ability to participate PARTIALLY MET
provided relief of in activities.
pain

 Encouraged and  To provide

assisted physical assistance and
activity consistent protect the patient
with the patient’s from injury.
energy levels.

 Have the patient  Helps in increasing

perform the activity the tolerance for the
more slowly, in a activity
longer time with
more rest or pauses,
or with assistance

 Gradually increase  Gradual progression

activity with active of the activity
range-of-motion prevents
exercises in bed, overexertion.
increasing to sitting
and then standing.
 ASSESSMENT
SUBJECTIVE DATA:
"Kanina lng ako
naoperahan" as RELATED TO POST-
verbalized by the patient
OBJECTIVE DATA:
•Temp. 36.6°c
•RUQ surgical wound
(11cm vertically)
•Weak in appearnace
•Clean and intack
abdominal dressing
NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
RISK FOR SHORT TERM: •Monitor redness, •These are the classic GOAL MET.
INFECTION •Within the shift patient swelling, increased pain, signs of infection. Any - Patient remains free of
will be able to identify purulent discharge from suspicious drainage infection, as evidenced
SURGICAL ways to reduce risk for incisions, injury, and should be cultured; by normal vital signs
INCISION infection exit sites of tubes (IV antibiotic therapy is and absence of signs
tubing), drains, or determined by and symptoms of
LONG TERM: catheters. pathogens identified. infection.
•At the end of - Early recognition of
hospitalization, patient infection to allow for
will not manifest any •Monitor elevated •Temperature of greater prompt treatment.
signs and symptoms of temperature than 37.7º (99.8º F) may - Patient will
infection indicate infection; very demonstrate meticulous
high temperature hand washing technique.
accompanied by
sweating and chills may
indicate septicemia.
•Wash hands and teach •Serves as first line of
patient and SO to wash defense. Friction and
hands before contact running water
with patients and effectively remove
between procedures microorganisms from
with the patient. hands. Washing
Instances when to wash between procedures
hands: reduces the risk of
- Before putting on transmitting pathogens
gloves and after taking from one area of the
them off. body to another. Wash
- Before and after hands with antiseptic
touching a patient, soap and water for at
before handling an least 15 seconds
invasive device (foley followed by alcohol-
catheter, IV catheter, based hand rub. If hands
and so on) regardless of were not in contact with
whether or not gloves anyone or anything in
are used. the room, use an
- After contact with alcohol-based hand rub
body fluids or and rub until dry. Plain
excretions, mucous soap is good at reducing
membranes, non-intact bacterial counts but
skin, or wound antimicrobial soap is
dressings. better, and alcohol-
- If moving from based hand rubs are the
contaminated body site best.
to another site during
the care of the same
individual.
- After contact with
inanimate surfaces and
objects in the immediate
vicinity of the patient.
- After removing sterile
or nonsterile gloves.
- Before handling
medications or
preparing food.
•For fast healing and
•Maintain aseptic drying of wounds.
technique when Aseptic technique
changing decreases the changes of
dressing/caring wound transmitting or
spreading pathogens to
the patient. Interrupting
the transmission of
infection along the chain
of infection is an
effective way to prevent
infection

•Keep area around •Wet area can be lodge

wound clean and dry area of bacteria

•If infection occurs, •Antibiotics work best

teach the patient to take when a constant blood
antibiotics as level is maintained
prescribed. Instruct which is done when
patient to take the full medications are taken as
course of antibiotics prescribed. Not
even if symptoms completing the
improve or disappear prescribed antibiotic
regimen can lead to
drug resistance in the
pathogen and
reactivation of
symptoms.