ASSESSMENT EXPLANATION OF OBJECTIVES NURSING RATIONALE EVALUATION

THE PROBLEM INTERVENTIONS

Subjective Data: Pain is an unpleasant STO: Dx: STO: (GOAL MET)

sensory and emotional
“Ang sakit nitong tiyan ko experience associated with Within 1-2 hour of Assessed the Gives a reliable source of Within 1-2 hour of
dahil sa sugat”. With a pain effective characteristics, quality, information that can help in effective nursing
acute or potential tissue
nursing interventions, the location, onset and severity planning an optimal pain interventions, the
scale of 4/10. damage, or described in patient will be able to: of pain. management strategy. patient:
terms of such damage;
Objective Data: sudden or slow onset of any  verbalize A normal response to  Verbalized
intensity from mild to decreased intensity Monitored for pain is an increase in decrease
 (+) facial grimace of pain from any changes in heart rate, breathing intensity of pain
 Guarding severe with an anticipated
or predictable end possibly 4/10 to 2/10. vital signs. rate and blood pressure. from 7/10 to
Behavior 3/10.
 Weak in evidenced by reports of
 express Observation may/
appearance incisional or phantom pain, willingness to may not be congruent  Expressed
observed guarding or participate in the Observed verbal with verbal reports willingness to
Nursing Diagnosis: protective behavior, pharmacologic and nonverbal indicating need for participate in
narrowed focus or self- regimen. cues, such facial further evaluation. the
PAIN related to abdominal grimacing, body pharmacologic
focus, and changes in vital
incision as evidence by the LTO: language, and regimen
signs.
presence of facial grimace restlessness. LTO:
and guarding behavior with Within 24-48 hours of Within 24-48 hours of
a pain scale of 4/10. nursing Tx: To manage the pain. nursing intervention,
intervention, the patient the patient:
will Administer pain  Demonstrate
be able to: medications as use of
prescribed, relaxation
 demonstrate use of ensuring proper techniques
relaxation dosing and
techniques timing and  Relieved from
evaluate the pain and
 relieve from pain medication improved
and effectiveness. comfort.
improve comfort. Relieves pain felt by the
patient.
Provided non
pharmacological
pain relief
interventions,
such heat or
cold therapy, distracted
techniques or
guided imagery
and deep
breathing
exercises. To alleviate the pain and to
provide comfort.
Assist the
patient in finding
comfortable
position
To determine if the
Edx: patient’s needs are
being met.
Assessed the
effectiveness of
the interventions
in relieving pain
by comparing
the patient’s
reported pain
levels to the
established
goals. Taking pain medicine
early prevents pain from
becoming unbearable.
Discussed the
importance of
taking pain
medication to maintain a
certain comfort To be able to provide
level. timely intervention.

Instructed the
patient and S/O
to notify a nurse
immediately
when
 experiencing
pain.

ASSESSMENT EXPLANATION OF OBJECTIVES NURSING RATIONALE NURSING

THE PROBLEM INTERVENTION RESPONSIBILITIES

Subjective Data: A risk of infection can be STO: Dx: STO:

identified when there is a
“Nakaramdam ako ng potential for the client to
parang may tumutulo na develop an infection due to
tubig tapos nong various factors or
circumstances. Prolonged
hinawakan ko” as
rupture of amniotic
Within 1-2 hours of (Goal met)
nursing Assess vital signs Fever is often the first sign Within 1-2 hours of
intervention, the regularly, paying of an infection. A nursing intervention,
patient will be close attention to any temperature the
able to: signs of fever. of greater than 37.7º patient:
verbalized by the patient. membranes before delivery  Maintain may indicate infection.
puts the mother and normal body  Maintained
Objective Data: neonate at increased risk temperature. normal body
 Elevated boy for infection. Many Inspect the surgical To prevent infection from temperature.
temperature pregnant clients with  Verbalize site or wound for signs worsening and to assess the
 Prolonged infections are understanding of of infection, such as healing process.  Verbalized
ruptured asymptomatic, infection. redness, swelling understanding
membrane necessitating both a high warmth or purulent of infection.
 Reduced Amniotic degree of clinical  Express drainage, or
fluid awareness and adequate willingness to increased pain Patients with  Expressed
screening (Smith & participate in the treatment inadequate nutrition may willingness to
Basistha, 2023). regimen. Assess and monitor be participate in
nutritional status, unable to muster a cellular treatment regim
NURSING DIAGNOSIS: LTO: weight, history of immune response to
RISK FOR INFECTION Within 24 hours of weight loss, and pathogens making them
related to prolonged nursing serum albumin. susceptible to infection.
rupture membranes and interventions, the LTO:
reduced amniotic fluid patient will: (Goal met)
To implement additional
 Displays no sign Within 24 hours of
infection prevention
And symptoms of nursing interventions,
measures and vigilant
infection. the patient will:
monitoring
 Identify Assess patient’s  Displayed no
interventions to immune status sign and
prevent or reduce including underlying symptoms of
To ensure it is dry and
risk of infection. conditions or infection.
intact,
 Demonstrates treatments, such as with no signs of leakage or
techniques and chemotherapy.  Identified
damage.
lifestyle changes interventions to
to promote safe Assess wound prevent or
environment. dressing. reduce risk of
 Retain infection.
To prevent spread of
maximum comfort
infections.
ability.
 Demonstrated
To support the body’s techniques
Tx: immune system and lifestyle
changes to
Ensure proper hand promote safe
hygiene. environment.
Promote proper  Retained
nutrition and Adequate sleep is an maximum
hydration, such as essential modulator of comfort ability.
eating foods high iron immune responses. A lack
and increasing fluid of
intake. sleep can weaken immunity
and increased susceptibility
Encourage sleep and to infection.
rest.
A clean and well-ventilated
surrounding inhibits the
growth of microorganism.

To prevent or treat bacterial

infections.

Keep the surrounding

clean and well
ventilated.
To allow the patient to
relax
while at rest and to
facilitate
Administer antibiotics effective stress
as prescribed management.

To allow enough
oxygenation
Edx: in the room.

Teach deep To help protect the patient

breathing exercises from acquiring infections
and during their hospital stay.
Relaxation
techniques. ❖ Antibiotics work best
when a
constant blood level is
Provide adequate maintained when
ventilation in the medications are taken as
room. prescribed. Not completing
the prescribed antibiotic
Educated the patient regimen can lead to drug
and family the resistance in the pathogen
importance of proper and reactivation of
hand hygiene and symptoms.
infection prevention
measures. To prevent complications

If infection occurs,
educate the patient
to take anti-infective
as prescribe and
instruct the patient to
take the full course of
antibiotics even if
symptoms improve or
disappear.

Educate the patient

and family of signs
and symptoms of
infection to report
promptly