St.

Paul University Dumaguete College of Nursing SY 2011-2012 NURSING CARE PLAN SUBJECTIVE CUES sakit pa akong tahi kung muhigda ko patakilid sa wala as verbalized by the patient. Pain scale of 6 with 10 as the highest and 0 as the lowest. OBJECTIVE CUES -facial grimace noted -guarding behavior on incision site. -irritability is observed NURSING DIAGNOSIS Acute Pain related to post operative incision. (TAH) SCIENTIFIC REFERENCE Acute Pain is an unpleasant sensory and emotional experience from actual or potential tissue damage. Total Abdominal Hysterectomy is a surgical procedure that removes your uterus through an incision in your lower abdomen. Reference: Nurses Pocket Guide edition 11 by Doenges page 499. PLANNING INTERVENTIONS RATIONALE EVALUATION

After 8 hours of nursing intervention the patient will be able to: - experience gradual reduction/ relief of pain.

After 8 hours of duty, the nurse was able to: -instruct patient to report any improvement/ exacerbation of pain.

After 8 hours of duty, the nurse was able to: -unrelieved pain can cause other problems such as anxiety, irritability, anger, immobility, respiratory problems and delay of healing.

-learn how to manage pain by herself by utilizing nonpharmacological measures. -provide comfort measures (warm compress) -encourage use of relaxation techniques

After 8 hours of nursing intervention, the patient was able to: -report any improvement of pain because patient is no longer irritable.

-to promote nonpharmacological - turn to her sides management with lesser pain. -to distract attention and to reduce attention.

-manage her pain when it occurs

St. Paul University Dumaguete College of Nursing SY 2011-2012 NURSING CARE PLAN

SUBJECTIVE CUES

OBEJECTIVE CUES

NURSING DIAGNOSIS

SCIENTIFIC REFERENCE

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

-administer analgesics as indicated to maximum dosage as needed.

-to maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal.

-drink medication with its effect to reduce her pain. -pain scale reduces to 3.

St. Paul University Dumaguete College of Nursing SY 2011-2012 NURSING CARE PLAN SUBJECTIVE CUES OBJECTIVE CUES NURSING DIAGNOSIS Risk for infection related to tissue destruction; invasive procedures. SCIENTIFIC REFERENCE Infection is the process of an increased risk for being invaded by pathogenic organisms. Total Abdominal Hysterectomy is a surgical procedure that removes your uterus through an incision in your lower abdomen. PLANNING INTERVENTIONS RATIONALE EVALUATION

After 30 minutes of nursing intervention, the patient will be able to: -verbalize understanding of and willingness to follow up prescribe regimen -demonstrate proper wound care

After 30 minutes of nursing intervention, the nurse was able to: -note risk factors for occurrence of infection

After 30 minutes of nursing intervention, the nurse was able to: -to evaluate presence/ character of infection -for mobilization of respiratory secretions and prevention of aspiration -to prevent drug resistance during premature discontinuation of regimen.

After 30 minutes of nursing intervention, the patient was able to: -verbalize understanding to follow up prescribed regimen -verbalize importance and demonstrate proper wound care

-encourage early ambulation, deep breathing, coughing and position changes -emphasize necessity of taking antibiotics as directed

Reference: -promote Nurses Pocket wellness Guide edition 11 by Doenges page 409.

St. Paul University Dumaguete College of Nursing SY 2011-2012 NURSING CARE PLAN

-teach proper wound care on incision site.

-to practice patient and significant other the proper way of doing wound care to prevent infection when discharged.

St. Paul University Dumaguete College of Nursing SY 2011-2012 NURSING CARE PLAN

SUBJECTIVE CUES dili pa nako kaya mabangon nga ako ra usa, dili pa ko makadaog sa akong lawas, kapoy pa kayo ko as verbalized by the patient.

OBJECTIVE CUES -fatigue -difficulty in rising from the bed -RR= 22cpm

NURSING DIAGNOSIS Activity Intolerance due to pain on incision site and fatigue.

SCIENTIFIC REFERENCE Activity intolerance is a risk of experiencing insufficient physiological energy to endure or complete required or desired daily activities. Total Abdominal Hysterectomy is a surgical procedure that removes your uterus through an incision in your lower

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

After 24 hours of nursing intervention, the patient will be able to: -do ADLs with less assistance from her significant others. -reports increase sense of well being -promote wellness

After 24 hours of nursing intervention, the nurse was able to: -determine current activity level and physical condition with observation -instruct client in activities in an alternate ways of doing it. -explain the importance of rest in the process of treatment

After 24 hours of nursing intervention, the nurse was able to: -provide baseline for comparison and opportunity to track changes -to conserve energy and to promote safety

After 24 hours of nursing intervention, the patient was able to: -do ADLs independently without assistance from her significant others.

- decrease the metabolic demands thus to conserve

St. Paul University Dumaguete College of Nursing SY 2011-2012 NURSING CARE PLAN abdomen. Reference: Nurses Pocket Guide edition 11 by Doenges page 74. energy.