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AssessmentNursing

DiagnosisPlanning Nursing Intervention Rationale Evaluation

S:Masakit and

sugat ko pag-gumagalaw

ako, asverbalized by

the patient.w/ a pain

scale of 8/10

O:-Guarded and

protective

behavior-Facialgrimace

-Flushed skin- slow

movement

Acute Pain r/tsurgical

incision.

After 1 hour of nursingintervention the pts

pain will be lessenedfrom pain scale of 8/10

to 2/10

Independent:

1. Note location surgical

procedures2. Perform pain assessment each

time pain occurs. Note changesform previous reports.

3. Monitor vital signs4. Provide comfort measures (e.g.

back rub, change in position andrelaxation exercises.

5. Provide quiet and calmenvironment.

6. Splint incision site when turning

position or coughing.7. Encourage adequate rest period.8. Encourage diversional activities.

Dependent:

9. Administer Ketorolac as ordered

1. This can influence the amount

of postoperative painexperienced.

2. To rule out worsening ofunderlying condition or

development of complications.3. Usually altered with acute pain.

4. To provide nonpharmacologicpain management.

5. To avoid stimuli and to promote

rest

6. To reduce pain at incision site7. To prevent fatigue8. To allay pts Attention from

pain

9. To relieve pain

Goal met, the patienspain was reduced to

2/10

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Assessment Nursing Diagnosis Objective Nursing Intervention Rationale Evaluation

S di akomakagalaw ng

maayos dahil sasugat o As

verbalized by thepatient

O- limited

movements- Slow movement

- looks weak

Altered PhysicalMobility r/t surgical

procedure (C/S)

After 1 hour ofnursing care, client

will demonstratetechniques and

behaviors that enableresumption of

activities

Independent:

1. Monitor V/S

2. Assist Client withactivities and provide use

of assistive devices3. Plan care between rest

periods.4. Instruct in use of side

rails5. Encourage adequate

intake of fluids/nutritious foods

6. Encourage expression offeelings

1. To provide baseline

data2. To prevent injury

3. To reduce fatigue4. For position

changes/ transfers5. Promotes well-

being andmaximizes energy

production6. To know the

feelings of thepatient, if she still

has questions orclarifications.

Goal met, the patientdemonstrated techniques

and behaviors that enableresumption of activities

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Assessment Nursing Diagnosis Objective Nursing Intervention Rationale Evaluation

O- Presence ofWound

- Post surgicalcondtion

Risk for Infection r/tsurgical incision

After 5hour shift,the patient will be

free from infection

Independent:

1. Monitor V/S2. Provided a clean

environment3. Stress proper

handwashing techniquesto relatives, caregivers

between therapies4. Maintain sterility for

invasive procedures5. Change dressing as

needed and indicatedDependent:

6. Administered amoxicillinas ordered

1. V/S is usually altered inan infection

2. This will reduce thepossibility of infection

3. This will reduce thepossibility of infection.

4. Prevent infection5. To prevent risk of

infection6. It is used for

prophylaxis (prevention)of possible infection

Goal met,after 5hour shift the

patient was freeform infection

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