ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS
Subjective: Within 20 INDEPENDENT DEPENDENT COLLABO- After 20 minutes
“Makirot ang hiwa ko Acute pain minutes of RATIVE of nursing
sa tiyan, lalo na pag related to nursing Assess: intervention, the
umuupo ako,” as abdominal intervention,  Assess client’s pain client:
stated by the patient. incision as the patient will scale (to be able to
evidenced by be able to: monitor progression of Demonstrated
8 out of 10 pain scale 8 out of 10 nursing interventions) participation in
pain scale  Participate  Monitor vital signs techniques to
in demo- every 4 hours relieve pain
Objective: nstrating Care: (proper
Vital Signs – techniques  Provide calm, quiet  Administe positioning,
BP – 110/90 mmHg to relieve environment r resting, and
PR – 80 bpm pain  Provide comfort mefenamic following
RR – 24cpm  Verbalize measures such as back acid q4° nonpharmacologi
Temp – 37.4°C eliminatio rub (to provide PO c pain regimens)
n/reduc- nonpharmacological (taking
Incision Site – tion of pain management) analgesics Verbalized
Wound dressing intact pain from lessens the reduction of pain
 Promote low Fowler’s
8 to 4. pain) from 8 to 5
position (low Fowler’s
S/Sx –
position reduces
Expressive behavior: Goal partially
intraabdominal
irritability, facial met.
pressure, thus reduces
grimacing
pain too)
Covers the incision
 Employ non-
site (guarding
pharmacologic pain
behavior)
distraction such as
No foul odor noted
music therapy, watching
Incision site warm and
television, and talking
reddened
to SOs. (distraction of
attention reduces pain
perception)

Teach:
 Teach client to eat fresh
 fruits vegetables and  Encourage
also to increase protein ambulatio
and fluid intake in the n as soon
diet (intake of foods as possible
that promote wound after birth
healing hastens (ambulati
healing of client’s on
wound, thus reduce decreases
and eliminate pain venous
from it) stasis and
 Encourage adequate rest increase
periods (to prevent platelets
fatigue) that
canpromo
te wound
healing)
ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUA-
DIAGNOSIS TION
Subjective: After 3 days of INDEPENDENT DEPENDENT COLLABO After 3 days of
n/a Impaired nursing RATIVE nursing
intervention, the Assess: intervention,
Objective:
skin integrity patient will be the patient was
related to  Assess the appearance, odor, and
Incision site – able to: drainage in the incision site (for able to:
surgical incision
7 cm horizontal documentation purposes and
as evidenced by
hypo-gastric Display gradual also serves as the baseline data Display gradual
7 cm incision
incision with and timely for future comparison) and timely
around
intact sutures healing on the healing on the
hypogastric area
incision site Care: incision site.
Open area  Perform hand hygiene before  (with MD)
moderate Participate in touching the incision site (to Administe Participate in
amount of sero- prevention prevent spread of micro- r prevention
saguineous measures that organisms) cephalexin measures that
drainage can hider wound  Keep the area of incision site 500mg PO can hinder
healing and clean and dry, carefully dress q6° to wound healing
No odor, skin treatment wound, and support incision (to prevent and treatment
around erythe- program assist body’s natural process of infection program
matous healing)  (with
 Use appropriate wound coverings nutritionis
Pain 8 out of 10 and skin-protective agents (to t) Provide
scale protect the wound and optimum
surrounding areas/structures nutrition
from trauma, injury, and and
microorganisms) increased
protein
Teach: intake to
 Assist the client/SOs in provide a
understanding and following positive
medical regimen and developing nitrogen
program of preventive care and balance
daily maintenance (enhances (to aid in
 commitment to plain, healing
optimizing outcomes) and to
 Teach the client on proper wound maintain
dressing (to prevent general
accumulation of microorganism good
on the incision site, and enhance health)
independence)
 Encourage early
ambulation/mobilize-tion
(promotes circulation and
reduces risks associated with
immobility)
ASSESSM NURSING PLANNING IMPLEMENTATION EVALUATION
ENT DIAGNOSIS
Subjective: Within 8 INDEPENDENT DEPENDENT COLLA- After 8 hours of
“Hindi pa Constipatio hours of BORATIVE nursing intervention,
ako nursing Assess: the client was able to
nakaka-
n related to interventions, establish bowel
decreased  Record fluid intake and
dumi,” as the patient output of the patient (to movement.
gastrointestina
verbalized will be able to evaluate hydration status)
l motility as
by the establish and  Note color, odor, Goal met.
evidenced by
client. regain normal consistency, amount, and
hypoactive
pattern of frequency of stool
bowel sounds
Objective: bowel (provides aseline
(+) hypo- function comparison and promotes
active recognition of changes in
bowel bowel)
sounds  Auscultate abdomen for
presence, location, and
Medica- characteristics of bowels
tions – sounds (reflects bowel
Ferrous activity)
sulfate
Mefenamic Care:
acid  Provide sitz bath after  Administer
stools (for soothing effect laxatives (stool
to the rectal area) softeners), mild
stimulants, or buk-
forming agents to
the patient, as
prescribed by the
physician (to aid
the nonpharma-
cologic nursing
interventions in
establishing
 bowel movement)

Teach:
 Instruct the patient to
increase fluid intake to
1500mL a day (to soften
the stool and for
hydration)
 Instruct in/encourage
balanced fiber and bulk in
diet (to improve
consistency of stool and
facilitate passage through
the colon)
 Promote high fiber fruit
juices, and suggest drinking
warm, stimulating fluids (to
promote moist/soft stool)
 Encourage activity/exercise
within limits of individual
ability (to stimulate
contraction of the
intestines)