Date done: July 4 2010

Problem Occurred: July 4 2010 at 9am

Assessment Diagnosis Planning Implementation Evaluation
Subjective: the Disturbed body After 8 hours of Intervention Rationale Goal met, After
patient verbalized image related to nursing the nursing
“naninibago ako the removal of intervention the Independent: interventions
sa aking left ovary as patient will  Assess  The extent of done the patient
kalagayan manifested by demonstrates perception of the response is demonstrates
ngayon” feelings of enhanced body change in more related to enhanced body
irritability and image and self- structure or the value or image and self-
discomfort. esteem as function of body importance the esteem as
evidenced by part (also patient places evidenced by
ability to look at, proposed on the part or ability to look at,
touch, talk about, change). function than touch, talk about,
and care for the actual value and care for
actual or or importance. actual or
perceived altered Even when an perceived altered
body part or alteration body part or
function. improves the function.
overall health of
Objectives: the individual.
 Feelings of  Assess impact of
irritability  Adolescents and
body image
and discomfort young adults
disturbance in
 Refusal to look may be
relation to
at, touch, or particularly
patient’s
care for altered affected by
developmental
body part changes in the
stage.
 Difficulty structure or
concentrating function of their
 Uncooperative bodies at a time
when
 With VS of
developmental
BP-110/80 mmHg
changes are
RR-19 Bpm
normally rapid,
PR-79 Bpm
and at a time
CR-75 Bpm
when developing
Temp.-36 0C
social and
 intimate
relationships is
particularly
 Acknowledge important.
normalcy of
emotional  Stages of grief
response to over loss of a
actual or body part or
perceived function are
change in body normal, and
structure or typically involve
function. a period of
denial, the
length of which
varies from
individual to
 Help patient
individual.
identify actual
changes.  Patients may
perceive
changes that are
not present or
real, or they
may be placing
unrealistic value
on a body
 Encourage structure or
verbalization of function.
positive or
negative  It is worthwhile
feelings about to encourage the
actual or patient to
perceived separate
change. feelings about
changes in body
structure and/or
function from
 Assist patient in feelings about
 incorporating self-worth.
actual changes
into ADLs, social  Opportunities for
life, positive
interpersonal feedback and
relationships, success in social
and situations may
occupational hasten
activities. adaptation.

 Teach patient
adaptive
behavior
 This
compensates for
actual changed
 Help patient body structure
identify ways of and function.
coping that have
been useful in  Asking patients
the past. to remember
other body
image issues
and how they
were managed
may help patient
adjust to the
current issue.
Date done: July 5 2010
Problem Occurred: July 5 2010
Assessment Diagnosis Planning Implementation Evaluation
Subjective: The Acute pain After 2 hours of Intervention Rationale Goal met. After 2
patient verbalized related to post nursing hours of nursing
“masakit ang surgical incision intervention the Independent: intervention the
tyan ko noon pa at the left lower patient will  Observe or  Some people patient verbalized
hangang ngayon” abdomen as verbalized relieve monitor signs deny the relieved of pain
on a pain scale of manifested by a to pain and will and symptoms experience of and described a
7/10 pain scale of 7/10 describe a associated with pain when it is reduction of
reduction of pain pain, such as present. painscale from
scale from 7/10 BP, heart rate, Attention to 7/10 to 3/10.
to 3/10. temperature, associated signs
color and may help the
moisture of nurse in
skin, evaluating pain.
restlessness,
Objective: and ability to
 Restless focus.
 Reduce  Different
interaction  Assess for etiological
with people probable cause factors respond
 Guarding of pain. better to
behavior different
 Grimacing therapies.
face
 Uncooperati  Some
ve  Assess patients may be
 Presence of patient’s unaware of the
post operative knowledge of effectiveness of
incision at the or preference nonpharmacolo
lower for the array of gical methods
abdomen pain-relief and may be
 With VS of strategies willing to try
BP-110/80 mmHg available. them, either
RR-19 Bpm with or instead
PR-79 Bpm of traditional
CR-75 Bpm analgesic
Temp.-36 0C medications.
Often a
combination of
therapies (e.g.,
mild analgesics
with distraction
or heat) may
prove most
effective.

 It is important
 Evaluate to help patients
patient’s express as
response to factually as
pain and possible (i.e.,
medications or without the
therapeutics effect of mood,
aimed at emotion, or
abolishing or anxiety) the
relieving pain. effect of pain
relief measures.
Discrepancies
between
behavior or
appearance and
what patient
says about pain
relief (or lack of
it) may be more
a reflection of
other methods
patient is using
to cope with
than pain relief
itself.
  One can
 Anticipate need most effectively
for pain relief deal with pain
by preventing it.
Early
intervention
may decrease
the total
amount of
analgesic
required.

Dependent:  Pain
 Give medications are
analgesics absorbed and
(Ketorolac) as metabolized
ordered, differently by
evaluating patients, so
effectiveness their
and observing effectiveness
for any signs must be
and symptoms evaluated from
of untoward patient to
effects. patient.
Ketorolac
Inhibits
prostaglandin
synthesis,
producing
peripherally
mediated
analgesia
and also has
antipyretic and
anti-
inflammatory
properties.