ASSESSMENT DATA

(Subjective & Objective Cues)

O:
guarded/protective behavior
restlessness
pallor
elevated pulse
respirations and systolic blood pressure
dilated pupils
report of 7/10 abdominal pain
NURSING DIAGNOSIS
Acute Pain related to tissue injury secondary to surgical intervention
GOALS AND OBJECTIVES
Short term goals
At the end of 2 hours nursing intervention, client will report pain is relieved or
controlled.
Long term goals
At the end of 8 hours nursing intervention, client will demonstrate use of
relaxation skills and diversional activities as indicated for individual situation.
NURSING INTERVENETIONS AND RATIONALE
I: Provide client optimal pain relief with prescribed analgesics.
R: Each client has a right to expect maximum pain relief. Optimal pain relief using
analgesics includes determining the preferred route, drug, dosage, and frequency for
each individual.
I: Teach the use of nonpharmacologic techniques (e.g., relaxation, guided imagery,
music therapy, distraction, and massage) before, after, and if possible during painful
activities; before pain occurs or
increases; and along with other pain relief measures.
R: The use of noninvasive pain relief measures can increase the release of endorphins
and enhance the therapeutic effects of pain relief medications.
I: Create a quiet, nondisruptive environment with dim lights and comfortable
temperature when possible.
R: Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to
focus on the relaxation technique rather than external distraction.
EVALUATION
Outcomes partially met. The client verbalizes pain and discomfort, requesting
analgesics at onset of pain. States the pain is a 2 (on ascale of 010) 30 minutes after
a parenteral analgesic administration. Requests analgesic 30 minutes before

ambulation. States willingness to try relaxation techniques; however, has not attempted
to do so.
ASSESSMENT DATA
(Subjective & Objective Cues)
S:
Report of fatigue and weakness
O:
Abnormal blood pressure response to activity
Inability to begin or perform activity
Exertional discomfort or dyspnea
NURSING DIAGNOSIS
Activity Intolerance related to pain
GOALS AND OBJECTIVES
Short term goals
At the end of 2 hours nursing intervention, client will participate willingly in
necessary/desired activities.
Long term goals
At the end of 2 days nursing intervention, client will demonstrate a decrease in
psychological signs of intolerance.
NURSING INTERVENTIONS AND RATIONALE
I: Assess the clients level of mobility.
R: This aids in defining what the client is capable of, which is necessary before setting
realistic goals.
I: Establish guidelines and goals of activity with the clients and caregiver.
R: Motivation is enhanced if the client participates in goal setting. Depending on the
etiological factors of activity intolerance, some clients may be able to live independently
and work outside the home. Other client with chronic debilitating disease may remain.
I: Assist client to plan with activities for times when they have most energy.
R: This promotes a sense of autonomy while being realistic about capabilities.
I: Teach ROM and strengthening exercise.
R: Exercise promotes increased venous return contractures, and maintain or increase
muscle strength.
EVALUATION
Goal met. Client was able to participate willingly in the activities and demonstrate a
decrease in psychological signs of intolerance.

ASSESSMENT DATA
(Subjective & Objective Cues)
S: Identifies object of fear; stimulus believed to be a threat
O: Increased pulse; vomiting; diarrhea; increased respiratory rate and shortness of
breath; increased systolic blood pressure; pallor; increased perspiration
NURSING DIAGNOSIS
Fear, related to possible development of choriocarcinoma.
GOALS AND OBJECTIVES
Short term goals
At the end of 2 hours nursing intervention, client will verbalize accurate
knowledge of/sense of related to current situation.
Long term goals
At the end of 2 days nursing intervention, client will acknowledge discuss fears
with health care provider or other professional.
NURSING INTERVENTIONS AND RATIONALE
I: Acknowledge normalcy of fear, pain, despair, and give permission to express
feelings appropriately/freely.

I: Encourage contact with a peer who has successfully dealt with a similarly
fearful situation.
R: Provides a role model, and client is more likely to believe others who have had
similar experience.

I: Establish rapport to client

R: To establish trust and cooperation on the client.

I: Encourage an attitude of realistic hope as a way of dealing with feelings of

helplessness
R: To help the patient to overcome her fear.

EVALUATION
Goals met. After 2 days of nursing intervention, the patient was able to eliminate
or reduce feelings of apprehension and tension and reduces disabling feelings worry
and panic.