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DATE CUES NURSING NURSING NURSING RATIONALE EVALUATION

Subjective/Objective DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjectives Moderate anxiety related After 2 hours of Monitor and record vital To have baseline data for After 2 hours of
“medyo kinakabahan to unfamiliarity with the nursing intervention signs comparison nursing
ako, ano ba gagawin surgical procedure as the patients will be intervention he
sakin dun?’ as evidence of increased able to report Establish rapport To develop patient trust client will be
verbalized by the blood pressure from and accurate result able to appear
patient 110/80 to 140/100.  decreased Talk to the patient and To help patients develop relax and report
Objective: fear explain further the understanding and trust to anxiety is
 Feeling nervous decreased procedure to be done health care provider reduced to
 Restless anxiety manageable
 Trouble in  decreased Identify patient perception It can point to the clients level.
concentrating blood about the upcoming level of anxiety
 Increased in pressure surgery
blood pressure  relax to a Helps patient to identify
from 110/80 to manageable Observed client behavior what is reality based.
140/100 level
Promote deep breathing To promote relaxation
and coughing exercise

Collaborative:
Administer anti
hypertensive drugs such as
SUBJECTIVE: “ hind Activity intolerance After 8 hours of Establish rapport to gain patient After 8 hours of
ako makalakad mag related to presence of nursing intervention cooperation and reduce nursing
isa” surgical incision as the pt will be able to anxiety intervention the
manifested by limited demonstrate a goal was met as
OBJECTIVE : mobility decrease in evidence by the
Weak in appearance physiological signs Asses patient ability to influence choices of patient
Facial grimace when of intolerance and perform ADL noting interventions or needed verbalized
moving do ADL with reports of weakness fatigue assistance partial
Limited mobility assistance and difficulty in dependence on
Surgical accomplishing task ADL such as
incision( RUQ) standing with
20 hours post op assistance
Surgical intervention: Encourage adequate rest rest between activities
open cholecystectomy periods provides time for energy
VS conservation and
 130/100mmhg recovery
 36.5
 18bpm Encouraged frequent deep
 68bpm breathing exercise promotes optimal chest
expansion
 Emphasized importance To promote circulation
of frequent ambulation

Encourage active range of To maximed full strenget

motion exercise like
flexing of both extremities.

Assist patient to do ADL To minimized fatigue

and to evaluate his
capabilities in doing such

Assist to do activity such To maximized full

as getting up to the bed strength
and going to the comfort
room