DISCUSSION

GOALS AND EVALUATION

ASSESSMENT OF THE INTERVENTIONS RATIONALE EVALUTION
OBJECTIVES CRITERIA
PROBLEM
Acute Pain Unrelieved LTO: Assess pain characteristics:  Appropriate pain assessment is the GOAL FULLY MET IF: GOAL FULLY MET:
related to acute pain After 8 hours of - Quality first step to achieve pain control. LTO: The patient “Medyo okay na
presence of leads to nursinginterventi - Severity (Ayasrah, O'Neill, Abdalrahim, experienced gradual ako. Hindi na siya
mechanical debilitation, ons, the patient - Location Sutary, & Kharabsheh, 2014). The reduction/relief of gaanong masakit.”
trauma diminished will be able to - Onset main goals of pain assessment are pain. Pain rated as 1/10.
secondary quality of life, experience - Duration to determine pain intensity, to
to post- and gradual - Precipitating or decide the dose and type of STO: The patient Patient was able to
operative depression. reduction/relief relieving factors analgesic drug, and to assess the reported pain is do deep breathing
wound. Unrelieved of pain. efficacy of the administered drug. controlled or exercises, had
acute Surgical nurses have important relieved, with a pain normal vital signs
Pain rated postoperative STO: tasks to achieve the stated goals scale of 2/10 from post-operatively.
as 7/10 pain leads to After 30 minutes (Yüceer, 2011) 7/10, demonstrated
characteriz development of nursing use of relaxation
ed as sharp, of chronic pain intervention, the  Assess for signs and  Some people deny the existence of skills and diversional
sudden, syndromes patient will be symptoms relating to pain. An increase in BP, HR, and activity such as deep
intermitten and increased able to: pain such as blood temperature may be present in a breathing exercises,
t, non- complications.  Report pain is pressure and heart rate. patient with acute pain. It is vital signs are within
radiating, In fact, controlled or recommended that pain is assessed normal range.
localized to unrelieved relieved, with along with other vital signs and it
the pain can kill. a pain scale of should be documented as the ‘fifth GOAL PARTIALLY
operative 2/10 from vital sign’ (Vickers et al, 2009). Post- MET IF:
site, Source: 7/10. operative pain should be assessed LTO: The patient
aggravated Medical-  Demonstrate regularly and systematically, at rest experienced
by Surgical use of and during movement, by gradualreduction of
movement, Nursing, 7th relaxation competent nurses (DH, 2010) pain but tolerable
relieved by ed. by Black, skills and pain is still present.
medication Joyce M. and diversional Assess the patent’s  Some patients may be satisfied when
s. Jane Hokanson activity such anticipation for pain relief. pain is no longer massive; others will STO: The patient
Grimace Hawks; p. 440 as deep demand complete elimination of reported pain is
and breathing pain. This influences the perceptions controlled with a
abdominal exercises. of the effectiveness of the treatment pain scale of 3-4/10
guarding  Maintain vital of the treatment modality and their from 7/10,
noted. signs within eagerness to engage in further demonstrated use
With normal range. treatments. of relaxation skills
limited and diversional
movements . activity such as deep
. Tx: breathing exercises,
Sweating Acknowledge reports of  Post-operative pain is a subjective vital signs are within
noted at pain immediately. experience and patient experiencing normal range and
 the it is the only person who can provide able to rest or sleep.
forehead an accurate description of it (Quality
and at the Improvement Scotland, 2004). POP is GOAL NOT MET IF:
back. a subjective experience and patient LTO: The patient
With experiencing it is the only person was not relieved
limited who can provide an accurate from pain.
answers to description of it (Quality
questions. Improvement Scotland, 2004) STO: The patient still
BP: 120/80 complains of a pain
PR: 80 Provide rest periods to  One’s experiences of pain may rating of 7/10 or
RR: 16 promote relief, sleep, and become exaggerated as a result of more, unable to
T0: 36.8oC relaxation. exhaustion. Pain may result in demonstrate
fatigue, which may result in diversional activity,
exaggerated pain. A peaceful and vital signs are
quiet environment may facilitate elevated and unable
rest. to rest or sleep.

Report to the physician  Patients who demand pain

when interventions are medications at more frequent
unsuccessful and intervals than prescribed may
ineffective. actually require higher doses or
more potent analgesics.
Edx:
Cognitive-behavioral  The aid of an imagined event or a
strategies as follows: mental picture involves use of the
 Imagery five senses to divert oneself from
 Distraction painful stimuli. Increasing one’s
techniques concentration, these techniques help
 Relaxation exercises, an individual decrease the pain
biofeedback, experience. Breathing modifications
breathing exercises, and nerve stimulations are some of
music therapy the methods. The aim of these
techniques is to lessen the stress,
tension, subsequently decreasing the
pain.

Encourage verbalization of  Only the client can judge the level

feelings about the pain.
anddistress of pain; pain
managementshould be a
teamapproach thatincludes the
client.Very few people lieabout
pain.(Medical-Surgical Nursing, 7th
ed. by Black, Joyce M.and Jane
 Hokanson Hawks; p. 443)

Instruct client toreport  Unrelieved paincan create other

anyimprovement/ problems such asanger,
exacerbation in anxiety,immobility,respiratory
painexperience. problems, anddelay in
healing.(Medical-Surgical Nursing,
7thed. by Black, Joyce M.and Jane
Hokanson Hawks; p. 443)

DISCUSSION
GOALS AND EVALUATION
ASSESSMENT OF THE INTERVENTIONS RATIONALE EVALUTION
OBJECTIVES CRITERIA
PROBLEM
Impaired Impaired tissue LTO: Dx: GOAL FULLY MET IF:
tissue integrity was After 3 days of Assess characteristics of  These findings will give information LTO: The patient
integrity due to the nursing wound, including color, on extent of injury. Pale tissue color was able to have a
related to client’s tissue intervention, the size (length, width, depth), is a sign of decreased oxygenation. progressive wound
post- trauma on the patient will be drainage, and odor. Odor may be a result of presence of healing and regain
operative surgical able to have a infection on the site; it may also be skin integrity
surgical incision site progressive coming from a necrotic tissue. Serous (wound reduces in
wound. from his recent wound healing exudate from a wound is a normal size) and the wound
surgery caused and regain skin part of inflammation and must be has no signs of
by small bowel integrity (wound differentiated from pus or purulent infection like pain,
Wound is obstruction. reduces in size) discharge, which is present in redness and foul-
characteriz Health and the wound infection. smelling discharges
ed as Implication: has no signs of in the wound and
___cm in The skin is a infection like Assess changes in body  Fever is a systemic manifestation of fever.
length, infectious pain, redness and temperature, specifically inflammation and may indicate the
approximat agents; foul-smelling increased in body presence of infection. STO: The patient
ely ___ cm however, any discharges in the temperature. demonstrated
in depth, break in the wound. proper wound care,
with skin can Tx: understood the
reddish readily serve as STO: Inspect the incision every  Frequent assessment can detect importance of
discharges a portal of After 8 hours of shift and document signs and symptoms of possible handwashing and
but not entry putting nursing findings. (Ralph & Taylor, infection. (Ralph & Taylor, 2008). identified the signs
foul- the individual intervention, the 2008). of wound infection.
 smelling, at risk for patient will be
with potential able to: Keep a sterile dressing  This technique reduces the risk for GOAL PARTIALLY
swelling infections  Demonstra technique during wound infection. MET IF:
and (Fundamentals te proper care. LTO: The patient
redness. of Nursing by wound was able to have a
With dry Kozier,et.al., care Administer antibiotics as  Wound infections may be managed progressive wound
and intact 7th  Understan ordered. well and more efficiently with topical healing and regain
dressing edition, page d the agents, although intravenous skin integrity
over the 633.) importance antibiotics may be indicated. (wound reduces in
operative of size) but shows
site. handwashi Note and report  Laboratory values are correlated with signs of infection
ng. laboratory values (e.g., client's history and physical like pain, redness
 Identify the white blood cell count and examination to provide a global view and foul-smelling
signs of differential, serum of the client's immune function and discharges in the
wound protein, serum albumin, nutritional status and develop an wound and fever.
infection and cultures). appropriate plan of care for the
like, pain, diagnosis (Lehmann, 1991). STO: The patient
swelling was not able to
and foul- demonstrate proper
smelling wound care but
discharges understood the
on the Edx: importance of hand
operative Instruct patient to avoid  Rubbing and scratching can cause washing and
wound rubbing and scratching. further injury and delay healing. identified some of
with the signs of wound
associated Teach skin and wound  Early assessment and intervention infection.
fever. assessment and ways to help prevent the development of
monitor for signs and serious problems. GOAL NOT MET IF:
symptoms of infection, The patient did not
complications, and improve at all and is
healing. not compliant with
the health teachings
Instruct and assist the  Proper hand washing is the most given.
patient with general effective method of disease
hygiene, including prevention. (Ralph & Taylor, 2008).
handwashing and toileting
practices. (Ralph & Taylor,
2008).

Encourage to eat protein  Wound healing is dependent on good

rich foods like egg, meat, nutrition and the presence of
cheese and fish. suitable polyunsaturated fatty acids
in the diet. Protein deficiency has
 been demonstrated to contribute to
poor healing rates with reduced
collagen formation and wound
dehiscence. High exudate loss can
result in a deficit of as much as 100g
of protein in one day. This
subsequently needs to be replaced
with a high protein diet. Vitamins are
also important in wound healing.

http://bhsrogers.weebly.com/uploads/6/1/0/1/6101925/examples_of_care_plans.pdf

wound infection control can be achieved using topical antiseptics, topical antibacterials, and systemic antibiotics. Novel methods such as photodynamic therapy and
silver-containing dressings will enable eradication of multidrug-resistant and biofilm-associated bacteria. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3428147/)
 DISCUSSION OF THE GOALS AND EVALUATION
ASSESSMENT INTERVENTIONS RATIONALE EVALUTION
PROBLEM OBJECTIVES CRITERIA
Risk for infection Observe and report  With the onset of
related to presence signs of infection infection the
of tissue trauma. such as redness, immune system is
Wound warmth, discharge, activated and signs
characterized as and increased body of infection appear.
___cm, with temperature.
associated pain,
slight swelling, no Note and report  Laboratory values
redness. laboratory values are correlated with
(e.g., white blood cell client's history and
count and physical examination
differential, serum to provide a global
protein, serum view of the client's
albumin, and immune function
cultures). and nutritional
status and develop
an appropriate plan
of care for the
diagnosis (Lehmann,
1991).

Assess skin for color,  Preventive skin

moisture, texture, assessment protocol,
and turgor including
(elasticity). Keep documentation,
accurate, ongoing assists in the
documentation of prevention of skin
changes. breakdown. Intact
skin is nature's first
line of defense
against
microorganisms
entering the body
(Kovach, 1995).
Observe incisions  Verifies status of
periodically, noting healing, provides for
approximation of early detection of
wound edges, developingcomplicat
hematomaformation ions requiring
and resolution, and prompt evaluation
presence of bleeding and influencing
and drainage. choice of
interventions.

Tx:
Carefully wash and  Maintaining supple,
pat dry skin, including moist skin is the best
skinfold areas. Use method of keeping
hydration and skin intact. Dry skin
moisturization on all can lead to
at-risk surfaces. inflammation,
excoriations, and
possible infection
episodes (Kovach,
1995)

Promote good  Protects patient

handwashing from sources of
procedures by staff infection, such as
and visitors. visitors and staff
Screen/limit visitors who may have an
who may have upper respiratory
infections. Place in infection (URI).
reverse isolation as
indicated.

Provide routine  Promotes healing.

incisional care, being Accumulation of
careful to keep serosanguineous
dressing dry and drainage in
sterile. subcutaneouslayers
increases tension on
suture line, may
delay wound
healing, and serves
as a mediumfor
bacterial growth.
Edx:
Encourage a balanced  Immune function is
diet, emphasizing affected by protein
proteins to feed the intake (especially
immune system. arginine); the
balance between
omega-6 and
omega-3 fatty acid
intake; and
adequate amounts
of vitamins A, C, and
E and the minerals
zinc and iron. A
deficiency of these
nutrients puts the
client at an
increased risk of
infection (Lehmann,
1991).

Encourage adequate  Chronic disease and

rest to bolster the physical and
immune system. emotional stress
increase the client's
need for rest (Potter,
Perry, 1993).

Encourage coughing  Helps reduce stasis

and deep breathing of secretions in the
exercises; frequent lungs and the
position changes. bronchial tree.
When stasis occurs,
pathogens can cause
upper respiratory
tract infections and
pneumonia.

Encourage frequent  Reduces pressure on

positional change, skin, promoting
inspect pressure peripheral
points, and massage circulation and
gently, asindicated. reducing risk of skin
Apply transparent breakdown. Skin
 skin barrier to elbows barrier reduces risk
and heels, if of shearing injury.
indicated.

Encourage  Topromotecirculatio
earlyambulation or n
mobilization. andreducesrisksasso
ciate withimmobility.

DISCUSSION OF THE GOALS AND EVALUATION

ASSESSMENT INTERVENTIONS RATIONALE EVALUTION
PROBLEM OBJECTIVES CRITERIA
Disturbed body STO: Dx:
image related to After 30 minutes of  Assess perceptionof  Extent of response
permanent nursing intervention, change ismore related to
alterations in body the patient will be instructure/functio the valveor
structure. able to: nof body part. importance patient
a. Verbalize places on the part
“Hindi understandin of function than
koineeexpectito. g of body the actualvalue or
Nahihiyanaakosasa changes importance.
rilikolalonasaasawa b. Seeks more
ko.” information  Assess impact of  Adolescents and
Poor eye contact. about her body image young adults may
With limited condition disturbance in be particularly
answers to relation to patient’s affected by
questions. developmental changes in the
stage. structure or
function of their
bodies at a time
when
developmental
changes are
normally rapid, and
 at a time when
developing social
and intimate
relationships is
particularly
important.

 Acknowledge and  Acceptance of this

accept expressionof feeling as a
feelings of normalresponse to
frustration, grief, what has occurred
hostility.Note facilitatesresolution
withdrawn . It is not helpful of
behavior and use of possible topush
denial. patient ready to
deal with
situation.Denial
maybe prolonged
and be anadaptive
mechanism because
patient isnot ready
to cope with
personal problems.
Tx:
 Note patient’s  There is a broad
behavior regarding range of behaviors
actual or perceived associated with
changed body part body image
or function. disturbance,
ranging from totally
ignoring the altered
structure or
function to
preoccupation with
it.

 Acknowledge  Stages of grief over

normalcy of loss of a body part
emotional response or function is
to actual or normal, and
perceived change in typically involves a
body structure or period of denial,
function. the length of which
 varies from
individual to
individual.

 Assist patient in  Opportunities for

incorporating positive feedback
actual changes into and success in
ADLs, social life, social situations
interpersonal may hasten
relationships, and adaptation.
occupational
activities.

 Involvepatient  Enhances feelingsof

inplanning competency/self-
careandschedulinga worth,encouragesin
ctivities. dependenceand
participationin
therapy.

 Open discussion of
 Provide accurate treatment and
information. prognosis may
Discuss concerns focus on current
about prognosis and
and treatment immediateneeds.
honestly at client’s Ongoing updates
level of acceptance. enable assimilation

Edx:  Providesopportunit
 Encourage y
verbalization of toidentifyfears/misc
positive or negative onceptions and
feelings about dealwith
actual or perceived themdirectly. It is
change. worthwhile to
encourage the
patient to separate
feelings about
changes in body
structure and/or
function from
 feelings about self-
worth.

 Actual change
 Discuss meaning of in body image
loss or change with may be
client and SO. different from
Assess interactions that perceived
between clientand by
SO. client.Distortio
ns may be
unconsciously
reinforced by
SO.

Anxiety related to presence of perceived threat to biologic integrity.