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Assessment

Diagnosis

Objectives

Nursing interventions

Rationale

Evaluation
S> Masakit itong
sugat ko.

> Patient rated
pain as 8 out of
10, 10 being the
highest and 1 as
lowest possible
pain
> Patient
described pain as
throbbing pain on
the surgical site
that is
precipitated by
moving and
applying
pressure.
>pain does not
radiate to other
body parts
O> An incision of
approximately 4-5
inches.
> Grimaces
noted.
> Guarding of the
Acute pain related to
tissue trauma
secondary to surgical
procedure.

STO> After 45
minutes to one
hour of nursing
interventions and
health teachings
the patient will be
able to verbalize
and demonstrate
the following
ways to relieve
pain:
a). coughing and
deep breathing
exercises.
b). active
interaction with
the people around
her.
c). compliance to
prescribed pain
medications.
LTO> After 2days
of nursing
interventions, the
patient will be
able to rate pain
as 2-3 from the
initial rate of 8 out
Dx:
> Assess for the level of
pain by ranking scale (o-
10), reports of pain,
location, quality, and
severity.

> Assess general health
status.



Tx:
> Established rapport


> Reposition on a semi-
fowlers position (when
indicated).




> Demonstrate deep
breathing and coughing
exercises.


Edx:
> Encourage the use of
relaxation techniques such
as deep breathing
exercises, listening to
music and talking with
significant others.
> Instruct patient to put
pillow or folded blanket on

> To be able to render a
more appropriate and
effective nursing care.


> To determine other body
parts that may be affected
by the operation and to
determine other
abnormalities.

> To gain trust from the
patient and the significant
others.

> May relieve pain and
enhance circulation. Semi-
fowlers position relieves
abdominal muscle tension.
it also relaxes and expands
the lungs

> Promotes relaxation and
relieve pain.

> Relieves muscle and
abdominal tension,
enhances sense of control,
promotes relaxation and
improve coping abilities.

> To lessen pain felt while
doing CE and prevent
wound dehiscence.
> Promote wellness and
avoid any adverse effects
STO> Goal fully
met. The patient
was able to
verbalized her
understanding of the
importance of the
following:
a). coughing and
deep breathing
exercises.
b). active interaction
with the people
around her.
c). compliance to
prescribed pain
medications.

LTO> Goal fully
met. The patient
was able to rate
pain as 2-3 from the
initial rate of 8 out of
10.

















surgical site when
in pain.
>With intact, dry
and clean wound
dressing.
of 10. the surgical site when
doing coughing exercises.

> Advice to comply with the
prescriptions made by the
doctor.
that may be caused by
incompliance.
Assessment Diagnosis Objectives Interventions Rationale Evaluation
S> nanghihina
ako
O> Limited
range of
motion.
> Slowed
movement.
> Perform
activities of
daily living with
assistance.
> Guarding of
post-surgical
area upon
movement.
A> Impaired
physical
mobility related
to pain
secondary to
surgical
operation.

Activity intolerance
related to pain
secondary to
surgical
opearation.
STO> After 30-
45 minutes of
nursing
intervention, the
patient will be
able to
understand and
verbalize
a). Importance
of early
ambulation.
a.1) for good
circulation
a.2) to prevent
adhesion of
internal organs.
b). Proper
compliance to
medication.
b.1) patient
verbalize that
he needs to
take
medications
with the right
the right dose at
Dx:
> Assess muscle
strength.


> Assess general status.



> Determine degree of
immobility.



> Assess degree of pain.


> Assess behavioral and
emotional responses to
pain.

Tx:
> Assist patient to
reposition in bed.



> Assist in performing
activities of daily living.

> Assist patient to
ambulate.



> Determine patients
ability to mobilize self.

> Know degree of
immobility in order to
render appropriate
nursing intervention.

> To provide appropriate
interventions and level of
care to be render.

> Degree of pain
contributes to immobility.

> Note factors affecting
pain and coping that may
impede goal attainment.

> Prevent the patient from
exerting too much effort; it
also improves blood
circulation that may aid in
making the healing
process faster.

> Maximize energy and
strength of the patient.

> Restore strength;
improve blood circulation
to aid in faster healing of
incision; avoid cohesion of
STO> The goal
was met because
the patient was
able to
understand and
verbalize the ff.
a). Importance of
early ambulation.
a.1) for good
circulation
a.2) to prevent
adhesion of
internal organs.
b). Proper
compliance to
medication.
b.1) patient
verbalize that he
needs to take
medications with
the right the right
dose at the right
time.
b.2) able to
enumerate the
importance of
the right time.
b.2) able to
enumerate the
importance of
complying to
medications.




LTO> After 2-3
days of nursing
intervention the
patient will be
able to:
a). Demonstrate
ROM exercise
like flexion and
extension of
upper
extremities.
b). Mobilization
like walking
from bed.



> Demonstrate deep
breathing and range of
motion exercises.



> Provide adequate
hours of rest and sleep.
> Provide comfort by
stretching the linens.

Edx:
> Encourage patient to
verbalize feelings and
concerns

> Encourage patient to
participate in activities as
tolerated.

> Encourage intake of
fluid and nutritious foods
especially foods rich in
protein like fish,
legumes, beans and
meat.


> Encourage patient to
ambulate for at least 5-7
24 hours post
operatively.


internal organs.

> Exercises like these can
contribute to relaxation of
muscle tension and relief
pain and provide comfort
to the patient.

> Reduces fatigue.

> Enhance self concept
and promote rest.


> Be able to render
appropriate and effective
nursing care.

> Enhance self-concept
and promotes
independence.

> Promote well-being and
maximize energy
production; helps in faster
wound healing and
restore or replace lost
body nutrients.

> Restore strength,
improve blood circulation;
aid in faster healing and
prevent cohesion of
microorganisms.


complying to
medications.



LTO> Goal was
met because the
patient was able
to:
a). Demonstrate
ROM exercise
like flexion and
extension of lower
extremities.
b). Mobilization
like walking from
bed.