NURSING DIAGNOSIS Subjective: Impaired Skin May tahi ako sa Integrity r/t tissue tiyan.

., as verbalized trauma secondary to by the client surgical incision as evidenced by (+) Objective: incison at lower quadrant V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg S/P TABHSO (+) incison at lower quadrant

CUES

GOAL

STG: After 3 days of proper nursing intervention, Independent: the patient display Inspect the wound timely healing of daily, or as wound without appropriate, for complications. changes.

NURSING INTERVENTION Establish rapport

RATIONALE

EVALUATION STG: Goal Met.

Promotes timely

intervention/revision of plan of care and to monitor progress of wound healing.

Keep the area clean and dry and stimulate circulation to surrounding areas, by encouraging early ambulation.

To assist bodys natural process of repair.

Provide optimum

nutrition, including vitamins such Vitamin C and increased protein intake.

To provide a positive
nitrogen balance to aid in skin/tissue healing and to maintain general good health.

Dependent: Administer antibiotics To inhibit the growth of microorganism. as ordered.

Provide changing of

wound dressing, as ordered by the physician and use an appropriate protective and healing devices (padding/cushion).

For wound healing and to protect the wound/or surrounding tissues.

Collaborative: Obtain specimen from draining wounds when appropriate for culture/sensitivity

To determine appropriate therapy.

Source:Nurses Pocket Guide,11th ed. by M. Doenges et al. p.619624

CUES

NURSING INTERVENTION

GOAL

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective: Masakit talaga yung tahi ko, as verbalized by the patient. - 1 is the lowest and 10 is the highest pain scale; Pain scale is 5/10 - dull pain -intermittent q2 Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg Guarding behavior, protecting body part (+)Facial grimace

Acute pain r/t tissue trauma secondary to surgical incision as evidenced by nonverbal cues such as (+) guarding and facial grimace

STG: Establish rapport After 1 hour of proper nursing intervention Independent: the patient reports Perform a that the pain is comprehensive relieved/ controlled. assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. Note changes.

STG: Goal Met. To rule out worsening of underlying condition/developmen t of complications. And in order to plan effective treatment.

Pain is a subjective Use pain experience and rating scale cannot be felt by appropriately (0-10 others. scale) and accept clients description of pain. Usually altered in acute pain.

Monitor skin color/temperature and vital signs.

To promote

Provide comfort

measure and encourage use of relaxation techniques such as touch, repositioning, nurses presence and deep breathing. Encourage verbalization of feelings about the pain.

nonpharmacological pain management and to distract attention and reduce tension.

Pain is a subjective experience and cannot be felt by others.

To maintain

Dependent: Administer analgesics, as indicated, to maximum dosage, as needed. Collaborative:

acceptable level of pain.

Source:Nurses Pocket Guide,11th ed. by M. Doenges et al. p.498503

CUES

NURSING DIAGNOSIS

GOAL

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective: Panay kasi ang ubo ko kaya medyo hirap ako minsan sa paghinga, as verbalized by the patient. Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg

Ineffective Airway

Clearance r/t ineffective cough as evidenced by (+) crackles

STG: Establish rapport After 3 days of proper nursing intervention, Independent: the patient's Assess changes in Tachycardia and secretions are vital signs and hypertension may be mobilized and airway temperature. related to increased is maintained free of work of breathing. secretions, as Fever may develop in evidenced by clear response to retained lung sounds and secretions/atelectasis ability to effectively . cough up secretions Monitor respirations Indicative of after treatments and respiratory distress and breathe sounds, deep breaths. and/or accumulation noting rate and of secretions. sounds. Note changes. Elevate head of bed or change positions every 2 hrs. or prn. To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage to different lung segment. Hydration can help liquefy viscous secretions and improve secretion clearance. Relaxes the main air passages bronchi and eases breathing Various therapies maybe require maintaining adequate airway, improving respiratory function and gas exchange.

STG: Goal Met.

(+) crackles
Cough

Increased fluid intake to at least 2000ml/day within cardiac tolerance. Dependent:

Give expectorant or
bronchodilators as ordered.

Collaborative: Assist with use of respiratory devices and treatments if necessary

Source:Nurses Pocket Guide,11th ed. by M. Doenges et al. p. 7781

CUES

NURSING DIAGNOSIS

GOAL

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective: Madalas akong magising dahil sa ubo, tapos isang oras bago ulit ako makatulog. as verbalized by the patient. Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg Restlessness

Disturbed Sleep STG: Establish rapport Pattern r/t frequent After 3 days of proper coughing as evidenced nursing intervention, Independent: by restlessness the patient achieves High percentage of Assessed sleep optimal amounts of sleep disturbances pattern disturbances sleep as evidenced by are affected by that are associated rested appearance, illnesses. with specific verbalization of feeling underlying illnesses. rested, and decrease in coughing. To facilitate Treat underlying treatment and cause.(cough) knowing the specific etiological factor will guide appropriate therapy. To determine usual Observed and sleep pattern and obtained feedback provide appropriate from clients intervention. regarding usual bedtime, routines, # of hours of sleep, and environmental needs. Did as much care as To avoid disturbances during sleep, and to possible without maximize sleeping waking the client, process. and did as much care as possible while the patient is still awake. So that patient will have an Explained necessity understanding of the of disturbances for importance of care monitoring VS and being done to him. care when Minimizes complaints hospitalized. Provide comfort measures (back rub). This soothes and relaxes the client.

STG: Goal Met.

Collaborative: Use of hypnotics or sedatives as ordered; evaluate effectiveness.

Because of their

potential for cumulative effects and generally limited period of benefit.

Source: Source: Nurses Pocket Guide,11th ed. by M. Doenges et al. p. 630

CUES

NURSING DIAGNOSIS

GOAL

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective: Nawawalan ako ng ganang kumain simula ng naospital ako, as verbalized by the patient. Diet Recall: Breakfast- Ensure (1 glass) Lunch- 4 tbs. of aroscaldo Dinner- 4 tbs. of aroscaldo Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 mmHg Wt: 37 kg Ht: 53 Decreased albumin (+) anemia (+) fatigue BMI: 14.45

Imbalanced Nutrition: Less than Body Requirements r/t disease process as evidenced by dietary intake

STG: After 1 week of nursing intervention, the patient will practice changes in her dietary intake by verbalizing selection of food and increase amount of food intakes including more nutritious foods in the diet.

Establish rapport Independent: Monitor weight regularly To establish baseline parameters and to monitor effectiveness of efforts Helps determine nutritional needs

STG. Goal Met.

Note age, body build, strength, activity/ rest level

To enhance intake Encourage client to and stimulate choose foods that appetite seems appealing and promote pleasant, relaxing environment Promote adequate/ timely fluid intake. Limits fluid 1 hour prior to meal Dependent: Administer pharmaceutical agents (Multivitamins) Collaborative: Consult dietician / nutritional team as indicated To reduce possibility of early satiety.

To increase appetite and nutritional intake

To implement interdisciplinary team management Source: Source: Nurses Pocket Guide,11th ed. by M. Doenges et al. p. 478-483

NURSING GOAL NURSING DIAGNOSIS INTERVENTION Subjective: Constipation r/t STG: Establish rapport changes in dietary After 2 days of proper Halos di ako intake as evidenced by nursing intervention Independent: makadumi kung hypoactive bowel the patient passes Assess usual di ako bibigyan ng soft, formed stool at a pattern of suppositories, as sound frequency perceived elimination; verbalized by the as "normal" by the compare with patient. patient. present pattern. Diet Recall: Include size, Breakfast- Ensure (1 frequency, color, glass) and quality. Lunch- 4 tbs. of aroscaldo Dinner- 4 tbs. of Evaluate laxative aroscaldo use, type, and frequency. Objective: V/S: T= 36.2 C PR= 78 bpm RR= 24 cpm BP= 130/90 Encourage daily mmHg fluid intake of 2000 to 3000 ml/day, if Hypoactive bowel not contraindicated sound medically.

CUES

RATIONALE

EVALUATION STG: Goal Met.

"Normal" frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is "normal" for each individual. Chronic use of laxatives causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. Patients, especially elderly patients, may have cardiovascular limitations, which require that less fluid is taken. Fiber passes through the intestine essentially unchanged. When it reaches the colon, it absorbs water and forms a gel, which adds bulk to the stool and makes defecation easier

Encourage increased fiber in diet (e.g., raw fruits, fresh vegetables); a minimum of 20 g of dietary fiber per day is recommended.

Encourage physical

Ambulation and/or abdominal exercises activity and regular strengthen exercise. abdominal muscles Ambulation and/or that facilitate abdominal exercises defecation. strengthen abdominal muscles