ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Constipation Short term goal:  Review daily  Inadequate Short term goal:
“Agtallo aldaw ti related to dietary dietary fiber
napalabas diay abdominal Within 6 hours of regimen,noting contribute to After 6 hours of
last nga panag muscle nursing if diet is poor intestinal nursing
cr ko,inggana weakness intervention ,the deficient in function intervention ,the
tatta awan secondary to patient will establish fiber patient were able to
pay ,kala takki post-operative or return to normal  Provides establish or return to
kalding tay surgery patterns of bowel  Noted baseline of normal patterns of
takkik idi “ as functioning color ,amount , comparison bowel functioning
verbalized by odor and
the patient Long term goal: consistency Long term goal:
and frequency
Objective : After 2 days of of stool After 2 days of
Nursing intervention Nursing intervention
As witnessed patient will:  Reviewed the  To determine patient
and claimed by - Verbalize clients current the drugs - Verbalized
her SO, the understandin medication contributing to understanding
patient was g of etiology regime constipation of etiology
consistently and and
lying down appropiriate  Auscultated appropriate
interventions abdomen for  Reflecting interventions
throughout the
- Demonstrate presence ,loca bowel sounds - Demonstrate
interview and
the previous few behavior tion and behavior
days. changes to characteristics changes to
prevent of bowel prevent
Limited recurrence of sounds recurrence of
movement as problem problem
seen  Encouraged  To help assist
fluid intake of in improving As evidenced by
Borborygmi 1-2 liters a day stool Bristol type 3
sounds of 4 within cardiac
 tolerance consistency
Distended
abdomen  Encouraged
patient to do  Stimulate
Bristol Type 1 as minimal peristalsis and
seen ambulation increase tone
of
gastrointestinal
tract and
abdominal wall
 Advised  Help decrease
patient to abdominal
avoid gas distention
forming foods

 Assisted and  To provide

instructed predictable
patient with and effective
other means elimination
triggering
defecation like
abdominal
massage or
suppositories

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 ASSESMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATION
S

Subjective: Acute pain Within 2 hours of  Noted  This can After 2 hours of
Madi ak unay related to nursing intervention, location of influence the nursing intervention,
makagaraw Post the patient will be able surgical, amount of the patient were able
gamin agsaki- operative to: Evaluate pain post-operative to:
sakit atuy sugat surgical characteristic pain
ko nukwa as incision at - Verbalize and s and experienced - Verbalize and
verbalized by the RUQ demonstrate intensity demonstrate
patient while relief and relief and
arm rubbing the control of pain  Performed  To demonstrate control of pain
right upper and discomfort pain improvement in and discomfort
quadrant assessment status
- Follow each time - Follow
Repeated pain prescribed pain occurs prescribed
with scale of 4/10 pharmacologica pharmacologica
l regimen  Administered  To maintain l regimen
Objective: analgesic acceptable
celecoxib as level of pain - Demonstrate
 Guarding - Demonstrate indicated to use of
behavior use of maximum relaxation skill
of putting relaxation skill dosage as and divertional
her arm and divertional needed. activities for
on her activities for  Provide and individual
abdomen individual  Provided promote non- situation
 Abdominal situation comfort pharmacologica
binder is measures of As evidenced by relief
l pain
seen back rub, pain from scale of
management
 Positionin change of 4/10 to 2/10 and
g to ease position, stable vital sign and
pain divertional complied in taking
medication on time
  Facial activities and
grimace use of
 4.5 cm relaxation
Kocher exercises .
incision  To prevent
with dry  Encouraged fatigue that can
and intact adequate rest impair ability to
dressing periods manage pain.

Vital sign:
BP- 130/100
RR- 24
O2 -95%

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Following a 1 day  Assess  High After a 1 day of
Paputol putol tulog Disturbed sleeping of nursing sleep percentage of nursing
ko kasi mayat- pattern related to intervention, the pattern sleep intervention, the
maya may mga interruptions for patient will achieve disturbances disturbances patient was able to
pumapasok na therapeutics, optimal amount of that are can affect the display
mga nars para monitoring and sleep as evidenced associated recovery of improvement in
magbigay gamot other generated by ; with the the patient sleeping pattern as
tapos maingay awakening and environment  To determine evidenced by;
paligid as excessive  Verbalization  Observe and usual
verbalized by the stimulation( noise of feeling obtain sleeping  The patient
patient and lightning) rested feedbacks pattern and to verbalized;
 Decrease regarding on compare if “medyo
the presence the usual there are any nakatulog at
Objective: of dark sleeping improvements nakapagpahinga
circles under pattern, on the na ako nang
Presence of dark the eyes maayos
bedtime sleeping
circles under the kumpara sa
 Improvemen routine and pattern of the
eyes dati”
t of sleeping the usual patient
pattern number of
Yawning  The patient
 Absence of hours of
restlessness sleep and does not
Restlessness
rest. look weak
 Do as much  To avoid and
care as disturbances restlessness
possible during sleep, compare to
without and also to the past
waking up maximize the  The
the client sleep and rest presence of
and do as of the client. eyebags
much care have been
as possible minimized or
while the have gone.
 client is still  Decrease of
awake  For the the usual
 Explain patient to yawning.
necessity of have an
disturbances understanding
for of the
monitoring importance of
vital signs care being
and care done to her
when and to
hospitalized minimize the
omplaints.
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ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION