Assessment Nursing Rationale Goal/Objective Intervention Rationale Evaluation

Diagnosis
Subjective: Pain related to Pain is one of Goal: Diagnostic Goal:
Patient verbalized abdominal the mos t After 8 hours of Assess pain scale Helps to determine After 8 hours of
“masakit yung tahi dito sa surgical incision complex human nursing effectiveness of therapy nursing intervention
tiyan ko. Mga 5 ang sakit (on abdomen experiences, is intervention for pain patient verbalized
niya pero kaya ko pang with a surgical an invisible patient will Monitor vital signs To monitor if there are pain scale of 3
tiisin. Sumasakit lang siya incision of 4 phenomenon report a decrease any changes
pag may kinakain ako o inches) influenced by of pain from 5 to Objective:
kaya pag masyado akong manifested by the interaction 4 and below. Therapeutic: After 4 hrs. patient
gumagalaw.” verbal report of of emotion, -Provide a quiet To minimize stress that was able to:
pain & guarding behavioral, Objective: environment patient is experiencing - demonstrate
Objective cues: behavior. cognitive and After 4 hrs. - Assist patient during To minimize feeling of different relaxation
Assessed pain scale, physiologic- patient will be activities pain techniques to
dressing is not soaked of sensory factors. able to: -Administer analgesic if To provide relief decrease pain
bloody discharge, Because pain is - demonstrate indicated through drug - understand a need
guarding behavior noted a highly different interaction for rest period after
when patient moves, facial individual relaxation each activity done
grimace noted experience, the techniques to Health Teaching: For client to understand
basis for pain decrease pain - Emphasize importance that rest periods after
management is - understand a rest periods after every each activity will
simply the need for rest activity relieve stress, muscle
client’s period after each tension & increase
verbalization of activity done. relaxation
pain.
Fundamental of
nursing,
CRAVEN p
1168
INTRA-OP
Assessment Nursing Rationale Goal/Objective Intervention Rationale Evaluation
Diagnosis
Objective cues: Risk for Any invasive Goal: Diagnostic Goal:
Patient’s vital signs is infection related device that After 8 hours of Monitor vital signs Helps to determine After 8 hours of
closely monitored, patient to surgical enters the body nursing effectiveness of therapy nursing intervention
is in a supine position, the procedure provides a portal intervention for pain patient did not
abdomen is exposed manifested by of entry for patient will not Assess incision site To monitor if there are manifest signs and
surgical microorganisms, manifest signs any changes symptoms of
instruments thus increasing and symptoms of Therapeutic: infection during the
introduced in the the chance infection during - Provide a clean whole procedure &
body infection. the whole environment To minimize stress that after the procedure.
Fundamental of procedure. - minimize touching the patient is experiencing
nursing, Craven incision To minimize feeling of Objective:
p 1039 Objective: pain After 4 hrs the
After 4 hrs the -Administer antibiotics if To provide relief patient was able to
patient will be indicated through drug recover from
able to recover interaction surgery without any
from surgery complications.
without any Health Teaching: Wound healing -was able to
complications. -instruct patient & family requires protein & understand
-will be able to importance of well- calories for building importance of well-
understand balanced diet high in new cells. The immune balanced diet.
importance of protein calories. system depends on
well-balanced -discuss sources of vitamin protein & calories to
diet. C & vitamin supplements produce antibodies.