NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
“umiiyak sya kapag nag SHORT TERM: INDEPENDENT:
- Goal partially met, After
babawas, masakit - Acute pain r/t to rectal -vital signs are usually
30 mins-1 hour of
siguro” mass After 30mins-1hr of - Assessed severity of increased as a result of
nursing intervention the
nursing intervention the pain, and vital signs autonomic response to
patient has verbalized
Objective: patient will be able to: pain
that the pain subsided
-facial grimace
from 8/10 to (4/10) and
-guarding behavior
verbalized relief from
-irritable - Provide restful, quiet - Reduces stimuli that
aches and pain
-rectal pain environment. may increase pain.
-Pain scale 8/10 -verbalize lowered pain
scale from 8/10 to 4/10
- Instruct patient deep - Helps patient to focus
breathing, relaxation less on pain, and may
techniques, guided improve efficacy of
imagery, massage and analgesics by
-show comfort while other nonpharmacologic decreasing muscle
sitting or straining aids. tension.

- Provide “donut
cushion” for the patient - Hemorrhoids are
to sit on if needed. exquisitely painful and
the patient may not be
able to sit in a chair and
apply pressure to
delicate tissues. Donut
cushions can help
 remove pressure from
hemorrhoid; caution on
the occurrence of
pressure areas.

DEPENDENT:

- Administer medications
as ordered such as - Pharmacological
paracetamol that can be Management to relieve
use as pain reliever if the pain.
patient is afebrile

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
SHORT TERM: INDEPENDENT:
Activity Intolerance r/t
to muscle weakness in After 30 mins –1 hour of Assessed the physical
“binubuhat ko sya kapag upper and lower limb NPI, the patient’s SO activity level, and
gusto nyang magbawas” will: mobility of the patient.
This also includes the
patient’s level of activity
intolerance and
muscular strength
-be able to understand
adaptive techniques to
perform activities of daily Established guidelines
living and goals of activity with
both patient and SO
Objective:
- Passive range of Provided emotional
motion support and positive
-muscle weakness in attitude regarding
upper and lower limb abilities
Have the patient
performed the activity
more slowly, more rest
and with assistance if
needed
Established rapport
about the importance of
assistance of patient
SHORT TERM:
Assessment is needed - Goal Met, After 30mins
to have a baseline – 1 hour of NPI the
information in patient accurately
formulating nursing verbalized
interventions understanding of
adaptive techniques to
perform daily living
Motivation and
cooperation are
enhanced if the patients
participates in goal
setting
Appropriate supervision
during early efforts an
enhance confidence
Helps in increasing the
tolerance for the activity
Coordinated efforts are
more meaningful and
 while avoiding patient effective in assisting the
dependency patient in conserving
energy

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
“Hindi daw lumalabas SHORT TERM: INDEPENDENT: SHORT TERM
kahit anong pag iri nya - Constipation r/t to - After 2hrs to 3hours of - Goal not Met, after 2-3
kapag nag babawas rectal mass as nursing intervention the - Assess patient’s stool - such as decreased
hours of nursing
sya” evidenced by frequency patient will verbalize frequency, rectal compliance, pain,
of stool is less than having an easier time characteristics, presence impairment of rectal intervention, the patient
Objective: normal. passing stools. of flatulence, abdominal sensation can lead to
did not have normal
discomfort or distension, constipation.
- Less than three bowel and straining at stool. elimination pattern
movements per week
reestablished and
- Adequate amounts of maintained.
- Monitor diet and fluid fiber and roughage
intake. provide bulk and
adequate fluid intake of
at least 2 L per day is
important in keeping the
stool soft.

- Gas, abdominal
- Monitor for complaints distention, or ileus, could
of abdominal pain and be a factor. Lack of
abdominal distention. peristalsis from impaired
digestion can create
 bowel distention and
worse to the point of
ileus.

- Improves peristalsis
- Provide a high-fiber and promotes
diet, whole grain cereals, elimination.
bread, and fresh fruits.

DEPENDENT:
- Pharmacological
-administer laxatives as Management to soften
doctor’s order the stools