Assessment Subjective: The patient verbalized: Masakit yung sugat ko Objective: The patient manifested : -irritability impairedphysical mobility

-disturbed sleep pattern -facial grimaces

Nursing Diagnosis Acute pain secondary to surgical operation

Planning Short term:

Inference

Nursing Rationale Interventions Establish rapport. To gain trust Emphasize ordered diet.

Evaluation Short term:

After 4 hours of nursing surgical incision interventions, the patients pain scale will there will be presence decrease 10/10 of trauma in the area to 5/10 Long term: After 1 day of nursing interventions, patients pain will diminish and perform activities like side movement and leg bending this damage will cause an inflammation of the nerves

Monitor vital signs. Provide comfort measure. Encourage deep breathing. Provide safety measure. Develop communication.

The patients pain scale To encourage decreased 10/10 to 5/10 patient not to eat untolerated Long term: food. To obtain The patients pain baseline data diminished and performed activities like To satisfy the side movements and leg confinement of bending patient To inhibit pain

there will be the presence of pain

To prevent from injury To alter pain and diminish emotional stress To reduce concern of unknown and associated muscle tension To maintain

review procedures/expecta tions and tell client when treatment will hurt. Administer analges

ics as indicated to maximal dosage as needed.

acceptable level of pain.

Assessment

O> the patient manifested: -Weakness -Pallor -with dry and intact dressing on the area. -Pain over the incision -Irritability -diaphoresis -fever

Nursing Planning Inference Diagnosis Risk for Short term: infection After 4 hours of secondary to impaired skin nursing surgical interventions, the incision patient shall identify and possible entry demonstrate of microorganism intervention to prevent infection Long term: After 1 day of nursing interventions, the patient will not have infection

Nursing Interventions >Establish rapport

Rationale >To gain trust

Evaluation Short term: The patient identified and demonstrated interventions to prevent risk of infection

>Monitor V.S.

>To obtain baseline data

Long term: >To reduce complication and >Note signs and monitor for infection The patient doesnt symptoms of sepsis experience infection >To reduce risk for >Provide wound healing therefore may cause such as cleaning of wound infection infection >Provide care, change dressing as needed >Encourage increase intake of Vitamin C >Encourage deep breathing exercise >To promote healing to the incision >To prevent infection to increase immune resistance >To increase healing of wound

Assessment

Nursing Planning Nursing Diagnosis Interventions > Establish rapport S> The patient Anxiety related Short term: to situational manifest: After 3 hours > Monitor vital signs crisis ofnursing - concerns due to change in life interventionsthe >Listen attentively; allow patient will event patient to verbalized awareness express feelingsverbally of feelings of anxiety - fear >Identify and reduce as Long term: - sleep many environment disturbance stressors After 1 day of nursing >Provide accurate O> The patient interventions the information about the manifest: patient will appear situation relaxed and report - extraneous anxiety is reduced to > Provide comfort movement a manageable level measures like back rub and soft music - irritability - insomnia - impaired attention >Use cognitive therapy

Rationale >To gain trust >To obtain baseline data

Evaluation Short term:

The patient verbalized awareness of feelings of >To allow patient to identify anxiety anxious behaviors and discover source of anxiety Long term: > Anxiety commonly results The patient appeared from lack of trust in the relaxed and reported that anxiety was reduced to a environment manageable level >Helps the patient what is reality based >To decrease autonomic response to anxiety

>To correct faulty catastrophic interpretations of physical symptoms

Assessment

Nursing Planning Diagnosis Fatigue related Short term: to physical O> the patient After 4 hours of condition nursing intervention, manifested: the patient will demonstrate an -Pale skin increase energy output with presence of -Impaired physical fatigue mobility -Irritability -Weakness -Pain= 5/10 -Activity intolerance -stress

Nursing Interventions >Establish rapport >Monitor vital signs

Rationale >To gain trust

Evaluation Short term:

>To obtain maintenance data The patient demonstrated increase energy output without presence of fatigue >Evaluate the need for >To determine degree of individual assistance and fatigue discuss lifestyle changes Long term: imposed by fatigue state The patient performed >Establish realistic activities of daily living and >Enhance commitment in Long term: activity goals with client promoting optimal outcomes participate in desired activities at level of After 3 day of nursing >Instruct client in ways >To indicate the need to alter activities intervention, the to monitor responses to activity level patient will perform activity and significant activities of daily signs and symptoms living and participate in desired activities at level of ability

Assessment S > The patient manifest: - thirst -weakness O> the patient manifested: -decrease urine output -sudden weight loss -decrease skin turgor -dry mucous membranes

Nursing Planning Diagnosis Risk for fluid Short term: volume deficit After 4 hours of nursing interventions the patient will identify risk factors and appropriate interventions Long term:

Nursing Interventions >Establish rapport >Monitor vital signs

Rationale >To gain trust >To obtain maintenance data

Evaluation Short term: The patient identified risk factors and appropriate interventions Long term:

> Encourage increase oral fluid intake

> To replace loss fluids The patient demonstrated behaviors or lifestyle changes to prevent development of fluid volume deficit

After 3 day of nursing interventions the patients will > Provide supplemental >Prevents peak in fluid level demonstrate fluids as ordered behaviors or lifestyle changes to prevent development of fluid >To ensure accurate picture volume deficit > Monitor intake and of fluid status output

> Provide safety measures

> Confusion can lead to accidents

> Encourage the use of oresol >To replace loss electrolyte.