NURSING INTERVENTION

ASSESSMENT DIAGNOSIS PLANNING EVALUATION

INTERVENTION RATIONALE

SUBJECTIVE: Pain related to After 4 hours of  Change the position  Pain is  After 4 hours
“Msakit ang tahi ko” tissue trauma and nursing of the patient sometimes due of nursing
as verbalized by the incisional intervention to the position intervention
patient. discomfort as patient’s pain of the patient the patient
manifested by evidenced by pain  Provide comfort  To reduce the reported pain
OBJECTIVE: grimace and pain scale =7 be measures discomfort was lessened
 Restlessness scale =7. reduced to 3.  Assist patient in  To assist in to pain scale
 Irritability breathing muscle and =3.
 With cold techniques generalized
clammy skin  Provide quiet relaxation
 Excessive environment  For patient
perspiration comfortabili-ty
 Facial and lessen the
grimace  Relay on the patient discomfort.
 Increased report of pain  To reduce
respiration  Encourage anxiety felt by
RR=26 bpm divertional the patient
 Pain scale = activities  To divert the
7: pain scaling attention from
of 1-10 where pain to
1 is the least activities
painful and 10  Monitor vital sign
is the most
painful  Administer  Usually altered
 Impaired analgesic as in pain.
thought ordered by the  To maintain
physician. acceptable level
of pain.
 NURSING INTERVENTION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

SUBJECTIVE: Impaired mobility After 8 hours of  Provide activities  To reduce the  After 8 hours
“Hindi ako related to nursing with adequate rest fatigue of nursing
makagalaw ng ayos” decreased muscle intervention the period. intervention,
as verbalized by the strength as patient will be the patient
patient. manifested by able move safety was able to
limited ROM. and  Encouraged  Promotes well move safely
OBJECTIVE: independently. adequate intake of being and with assistive
 Impaired fluids maximize device.
ability to turn energy
side to side. production
 Cannot eat
without  Advise to move  To
support hands and legs exercise/mobili
 Slowed slowly zation of body
movement parts and
 Irritable develop muscle
 Limited ROM strength

 Encourage  Enhances self

participation in self concept and
care sense of
independence
 NURSING INTERVENTION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

SUBJECTIVE: Pain related to After 4 hours of  Change the position  Pain is  After 4 hours
“Masakit ang tahi ko” tissue trauma and nursing of the patient sometimes due of nursing
as verbalized by the incisional intervention to the position intervention
patient. discomfort as patient’s pain of the patient the patient
manifested by evidenced by pain  Provide comfort  To reduce the reported pain
OBJECTIVE: grimace and pain scale =7 be measures discomfort was lessened
 Restlessness scale =7. reduced to 3.  Assist patient in  To assist in to pain scale
 Irritability breathing muscle and =3.
 With cold techniques generalized
clammy skin  Provide quiet relaxation
 Excessive environment  For patient
perspiration comfortabili-ty
 Facial and lessen the
grimace  Relay on the patient discomfort.
 Increased report of pain  To reduce
respiration  Encourage anxiety felt by
RR=26 bpm divertional the patient
 Pain scale = activities  To divert the
7: pain scaling attention from
of 1-10 where pain to
1 is the least activities
painful and 10  Monitor vital sign
is the most
painful  Administer  Usually altered
 Impaired analgesic as in pain.
thought ordered by the  To maintain
physician. acceptable level
of pain.
 NURSING INTERVENTION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

OBJECTIVE: Fluid volume After 8 hours of  Change dressings  To protect the  After 8 hours
 Poor skin deficit related to nursing frequently skin and of nursing
turgor the risk of post- intervention the  Provide frequent monitor lossess intervention,
 Dry lips operative patient will oral care  To prevent the patient has
 Weak in hemorrhage as maintain fluid at a  Measure input and injury from a normal urine
appearance manifested by functional level. output dryness output.
 Pale looking poor skin turgor,  Monitor v/s  Helps
 v/s of: dry lips.  Administer IV maintaining
BP = 100/80 fluids as indicated fluid in the
PR = 64  Give medications body
RR = 26 as ordered by the  To monitor
T = 37.8 attending physician fluids in the
body
 To assess the
patient and it
serve as base
line data
 To reduce blood
loss