ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Objective Cues: Long-term goal… • Facilitate to • To provide early Patient condition

• With surgical Partially compensatory inspect incision detection on improved.
incision @ At the end of 8 hrs. and dressing. infectious desease.
perineal area Nursing intervention,
• Asleep most of patient will display • Facilitate to • To monitor
the time timely healing of wound assess skin turgor peripheral
• Body w/out complications. and capillary circulation and
temperature of refill cellular hydration.
37.4o C
• With protective • Facilitate to • To monitor the
behavior. monitor vital presence of
• On soft diet signs. (Onset of infections and
• Ambulatory fever, chills, development of
diaphoresis, and sepsis.
Nursing Diagnosis: other unsafely
Impaired skin symptoms.
integrity related to
surgical procedure. • Kept the area • To assist body’s
(Fistulectomy) clean and dry natural process of
repair.

• Performed hot • To promote good

sitz bath circulation and it
reduces pain.
 ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Cues: Short-term goal… • Facilitate to • To monitor the Patient condition

“Medyo masakit ang Partially compensatory monitor vital presence of improved.
opera ko” as patient At the end of 1 hr. signs. infections and
verbalized. nursing intervention, development of
patient’s pain will sepsis.
Objective Cues: relieved. • Facilitate to • To rule out
• With surgical assess pain each worsening of
incision @ time pain occurs. underlying condition
perineal area and development of
• Pain scale of complications.
4/10
• With discomfort • Provided comfort • To provide
movement measures such as nonpharmacologic
• With protective (hot sitz bath) pain management.
behavior • Encouraged deep • It reduces pain
• On soft diet breathing sensation.
• Ambulatory exercises • It helps to lessen the
• Encouraged pain sensation in
Nursing Diagnosis: diversional doing some activities
Acute pain related activities such as
to surgical procedure Such as (watching tv,
(Fistulectomy) listening to radio and
socialization w/
others.