Nursing Nursing Scientific Planning Nursing Rationale Expected Outcome

assessment Diagnosis Explanation Interventions

S> -- Surgery is After 2-4 1. Established To gain After 2-4 hours of
Risk for the hours of rapport. cooperation nursing
O> Pt. may infection treatment of nursing & pt’s level intervention the
manifest: related to choice for intervention of anxiety patient was able to
• Rising surgical AAA more the patient identify
temperature. wound than 5.5cm will be able 2. Monitor To get intervention to
• Inadequate wide or to identify Vital signs baseline data reduce risk of
acquired those that intervention infection.
immunity. are to reduce
enlarging. risk of 3. Observed To rule out After 2-3 days of
The standard infection. for the worsening nursing
treatment localized condition intervention the
has been After 2-3 signs of patient was able to
open days of infection at be free of purulent
surgical nursing insertion drainage.
repair of the intervention sites of
aneurysm by the patient surgical
resecting the will be able wounds.
vessel and to be free 4. Stressed A first line of
sewing the of purulent proper hand defense
bypass graft drainage. hygiene by against health
in place. all care-
After the caregivers associated
procedure between infection
there will be therapies
an open and patient.
wound in 5. Monitored To limit
surgical patient’s exposures,
incision sites visitors/car thus, reduce
that attracts egiver for cross
bacterial respiratory contamination
colonization. illness
offer mask
and tissues.
6. Administer
medication
regimen
such as
antibiotics
and note
client
response.
Nursing assessment Nursing Scientific Planning Nursing Rationale Expected
Diagnosis Explanation Intervention Outcome
S> -- Acute pain 1. Established To gain
related to rapport. cooperation &
O> Patient vascular pt’s level of
manifested: enlargement- anxiety
rupture as
• Observed evidence by 2. Monitor To get baseline
evidence of guarding Vital signs data
pain behavior, facial
• Falling mask,
blood irritability, 3. Obtained To rule out
pressure restlessness. client’s worsening of
• Guarding assessment underlying
behavior of pain to condition.
• Facial mask include
• Sleep locations,
disturbance characteristi
cs, onset,
• Restlessness
frequency,
• Irritability quality,
• Change in intensity &
abdominal aggravating
muscle tone factors.
from listless 4. Accept Pain is a
to rigid client’s subjective exp.
• Reduced descriptions & cannot be felt
interaction of pain by others.
with people
&
environmen 5. Provide To promote non-
 t comfort pharmacological
• Impaired measure pain
thought such as management.
process touch,
repositionin
g, use of
cold/heat
packs, nurse
presence.
6. instruct in To distract
use of attention and
relaxation reduce tension.
techniques,
such as
focused
breathing,
imaging.
7. administered To maintain
analgesics, acceptable level
as indicated of pain.
to maximize
dosage as
needed.