DATE

&
TIME
F
E
B
R
U
A
R
Y

CUES
SUBJECTIVE:
Sakit paman
gud ang tahi
maam maong dili
kaayo ko
kalihok, as
verbalized by the
patient.

12,
2013
@
4 pm

OBJECTIVE:
- Undergon
e TAH
- Pain
scale:
8/10 Horrible
- Weak
- Guarding
of incision
site
- Needs
assistanc
e when
sitting and
walking
- Dizziness
when
ambulatin
g

NEED
A
C
T
I
V
I
T
Y
E
X
E
R
C
I
S
E
P
A
T
T
E
R
N

NURSING
DIAGNOSIS
Activity
intolerance r/t
surgical incision
secondary to
Total Abdominal
Hysterectomy
(TAH)
RATIONALE:
Surgical incision
due to Total
Abdominal
Hysterectomy
(TAH) causes
pain that
stimulates pain
receptors which is
then transferred
and processed in
the brain then
sends an impulse
down the spinal
cord commanding
the body to react
like decrease
performance of
daily activities,

OBJECTIVES OF
CARE

NURSING
INTERVENTIONS

Within 4 hours
span of care, the
patient will be
able to increase
activity
level
within capabilities
as evidenced by:

1. Assess patients

a. perform active
ROM exercises

before settling

b. sit without
assistance

2. Administer

c. unguarding of
incision site

as ordered.

level of mobility.

EVALUATION
February 12, 2013
@

R: This aids in
defining what the
patient is capable of,
which is necessary
realistic goals.
medications for pain
R: To alleviate pain
3. Take safety
measures such as
raising of side rails
and keeping bed in
low position.
R: To reduce risk for
injury
4. Keep objects the
patient may need

8 pm
GOAL
PARTIALLY MET
Within 4 hours
span of care, the
patient was able to
increase activity
level within
capabilities as
evidenced by:
a. performed
active ROM
exercises such as
arm exercises,
hand and finger
exercises, foot
exercises, leg
flexion and leglifting exercises.
b. patient was able
to sit without
assistance from

Vital
Signs:
PR=69-71
bpm
CR-71-74
bpm
Medicatio
n given for
pain:
Paraceta
mol +
Tramadol
(Analgesic
)

weakness,
dizziness, and
guarding of
incision site.

within reach.

Reference:
Health
24(2013).Retrieve
d on February 26,
2013 from
http://www.health
24.com/Medical/P
ain/Aboutpain/Physiologyof-pain-20120721

5. Encourage active

R: To prevent injury
from overreaching,
bending, or falling

ROM and
strengthening
exercises.
R: To promote
increase venous
return, prevent
contractures, and
maintain muscle
strength
6. Assist with ADLs
as indicated except
those the patient can
do alone.
R: To allow energy
conservation; to
balance providing
assistance with

the student nurse

or watcher
c. patient still
guards the incision
site on her
abdomen

facilitating
progressive
endurance that will
ultimately enhance
patients activity
tolerance
7. Encourage to
change position often
when lying or sitting.
R: This distributes
work to different
muscles to avoid
fatigue
8. Encourage to rest
at least 1 hour after
meals before starting
a new activity.
R: Energy is needed
to digest food.
9. Keep objects the
patient may need
within reach.
R: To prevent injury

from overreaching or
falling
10. Provide
emotional support
while increasing
activity; promoting
positive attitude
regarding abilities.
R: Patients may be
fearful of
overexertion and
potential damage.
Appropriate
supervision during
early efforts can
enhance confidence.

MIRALLES, EVE
VANESSA G., ST.
N