NURSING CARE PLAN CUES NURSING DIAGNOSIS Self-care deficit r/t weakness, discomfort and postoperativ e pain OBJECTIVES

Short term Subjective Patient verbalized, Usahay, dili ko ganahan mag lihok-lihok kay mu andar man ang kasakit maong magpuyo-ay ra ko. Mga 8 tingali ang kasakit niya. as verbalized by the patient. Dili pako kalihok nga ako lang isa as verbalized by the patient. Luya pako karon kay bago rako naoperahan as verbalized by At the end of 4 hours of nursing interventions, the patient will be able to: tolerate the passive performanc e of A.D.L.s such as eating, changing clothes, and bathing in bed. Long term At the end of 2 days of nursing interventions, the patient will be able to: perform ADLs, such as eating, changing, toileting, and bathing by herself. INTERVENTIONS Independent Assist with meeting clients needs when she is unable to meet own needs. Encourage SOs participation in problem identification and desired goals and decision making. Allow sufficient time for client to accomplish tasks to the fullest extent of abilities. Avoid unnecessary interruptions. RATIONALE EVALUATION

To allow patient to perform vital tasks while recuperating. To enhance commitment to plan, optimizing outcomes, and supporting recovery and health promotion. To maximize functionality and optimize self-care routine.

To encourage client and build on

the patient. Patient verbalized that her mother assists her in tasks.

Assist with necessary adaptations to ADLs. Begin with familiar, easily accomplished tasks. Provide privacy and equipment within easy reach during personal care activities. Encourage rest periods.

successes.

To facilitate task at hand.

Objective patient was observed slightly untidy has slightly unpleasant body odor observed grimacing, moving in a guarded or protective manner, and holding or supporting the painful body area. General weakness

To prevent fatigue.

To provide pharmacologic pain relief and enhance wellbeing.

Dependent Administer or monitor the administratio n of prescribed analgesics (i.e. Ketorolac, Tramadol)

noted Preference for immobility observed