Ncp
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NURSING INTERVENTION ASSESSMENT SUBJECTIVE: “Msakit ang tahi ko” as verbalized by the patient. OBJECTIVE: Restlessness Irritability With cold clammy skin Excessive perspiration Facial grimace Increased respiration RR=26 bpm Pain scale = 7: pain scaling of 1-10 where 1 is the least painful and 10 is the most painful Impaired thought
DIAGNOSIS Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.
PLANNING After 4 hours of nursing intervention patient’s pain evidenced by pain scale =7 be reduced to 3.
INTERVENTION Change the position of the patient Provide comfort measures Assist patient in breathing techniques Provide quiet environment Relay on the patient report of pain Encourage divertional activities
RATIONALE Pain is sometimes due to the position of the patient To reduce the discomfort To assist in muscle and generalized relaxation For patient comfortabili-ty and lessen the discomfort. To reduce anxiety felt by the patient To divert the attention from pain to activities
Monitor vital sign Administer analgesic as ordered by the physician.
Usually altered in pain. To maintain acceptable level of pain.
EVALUATION After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.
NURSING INTERVENTION ASSESSMENT SUBJECTIVE: “Hindi ako makagalaw ng ayos” as verbalized by the patient. OBJECTIVE: Impaired ability to turn side to side. Cannot eat without support Slowed movement Irritable Limited ROM
DIAGNOSIS Impaired mobility related to decreased muscle strength as manifested by limited ROM.
PLANNING After 8 hours of nursing intervention the patient will be able move safety and independently.
INTERVENTION
RATIONALE
Provide activities with adequate rest period.
To reduce the fatigue
Encouraged adequate intake of fluids
Promotes well being and maximize energy production
Advise to move hands and legs slowly
To exercise/mobili zation of body parts and develop muscle strength
Encourage participation in self care
Enhances self concept and sense of independence
EVALUATION After 8 hours of nursing intervention, the patient was able to move safely with assistive device.
NURSING INTERVENTION ASSESSMENT SUBJECTIVE: “Masakit ang tahi ko” as verbalized by the patient. OBJECTIVE: Restlessness Irritability With cold clammy skin Excessive perspiration Facial grimace Increased respiration RR=26 bpm Pain scale = 7: pain scaling of 1-10 where 1 is the least painful and 10 is the most painful Impaired thought
DIAGNOSIS Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.
PLANNING After 4 hours of nursing intervention patient’s pain evidenced by pain scale =7 be reduced to 3.
INTERVENTION Change the position of the patient Provide comfort measures Assist patient in breathing techniques Provide quiet environment Relay on the patient report of pain Encourage divertional activities
RATIONALE Pain is sometimes due to the position of the patient To reduce the discomfort To assist in muscle and generalized relaxation For patient comfortabili-ty and lessen the discomfort. To reduce anxiety felt by the patient To divert the attention from pain to activities
Monitor vital sign Administer analgesic as ordered by the physician.
Usually altered in pain. To maintain acceptable level of pain.
EVALUATION After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.
NURSING INTERVENTION ASSESSMENT OBJECTIVE: Poor skin turgor Dry lips Weak in appearance Pale looking v/s of: BP = 100/80 PR = 64 RR = 26 T = 37.8
DIAGNOSIS Fluid volume deficit related to the risk of postoperative hemorrhage as manifested by poor skin turgor, dry lips.
PLANNING After 8 hours of nursing intervention the patient will maintain fluid at a functional level.
INTERVENTION Change dressings frequently Provide frequent oral care Measure input and output Monitor v/s Administer IV fluids as indicated Give medications as ordered by the attending physician
RATIONALE To protect the skin and monitor lossess To prevent injury from dryness Helps maintaining fluid in the body To monitor fluids in the body To assess the patient and it serve as base line data To reduce blood loss
EVALUATION After 8 hours of nursing intervention, the patient has a normal urine output.
DIAGNOSIS Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.
PLANNING After 4 hours of nursing intervention patient’s pain evidenced by pain scale =7 be reduced to 3.
INTERVENTION Change the position of the patient Provide comfort measures Assist patient in breathing techniques Provide quiet environment Relay on the patient report of pain Encourage divertional activities
RATIONALE Pain is sometimes due to the position of the patient To reduce the discomfort To assist in muscle and generalized relaxation For patient comfortabili-ty and lessen the discomfort. To reduce anxiety felt by the patient To divert the attention from pain to activities
Monitor vital sign Administer analgesic as ordered by the physician.
Usually altered in pain. To maintain acceptable level of pain.
EVALUATION After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.
NURSING INTERVENTION ASSESSMENT SUBJECTIVE: “Hindi ako makagalaw ng ayos” as verbalized by the patient. OBJECTIVE: Impaired ability to turn side to side. Cannot eat without support Slowed movement Irritable Limited ROM
DIAGNOSIS Impaired mobility related to decreased muscle strength as manifested by limited ROM.
PLANNING After 8 hours of nursing intervention the patient will be able move safety and independently.
INTERVENTION
RATIONALE
Provide activities with adequate rest period.
To reduce the fatigue
Encouraged adequate intake of fluids
Promotes well being and maximize energy production
Advise to move hands and legs slowly
To exercise/mobili zation of body parts and develop muscle strength
Encourage participation in self care
Enhances self concept and sense of independence
EVALUATION After 8 hours of nursing intervention, the patient was able to move safely with assistive device.
NURSING INTERVENTION ASSESSMENT SUBJECTIVE: “Masakit ang tahi ko” as verbalized by the patient. OBJECTIVE: Restlessness Irritability With cold clammy skin Excessive perspiration Facial grimace Increased respiration RR=26 bpm Pain scale = 7: pain scaling of 1-10 where 1 is the least painful and 10 is the most painful Impaired thought
DIAGNOSIS Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.
PLANNING After 4 hours of nursing intervention patient’s pain evidenced by pain scale =7 be reduced to 3.
INTERVENTION Change the position of the patient Provide comfort measures Assist patient in breathing techniques Provide quiet environment Relay on the patient report of pain Encourage divertional activities
RATIONALE Pain is sometimes due to the position of the patient To reduce the discomfort To assist in muscle and generalized relaxation For patient comfortabili-ty and lessen the discomfort. To reduce anxiety felt by the patient To divert the attention from pain to activities
Monitor vital sign Administer analgesic as ordered by the physician.
Usually altered in pain. To maintain acceptable level of pain.
EVALUATION After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.
NURSING INTERVENTION ASSESSMENT OBJECTIVE: Poor skin turgor Dry lips Weak in appearance Pale looking v/s of: BP = 100/80 PR = 64 RR = 26 T = 37.8
DIAGNOSIS Fluid volume deficit related to the risk of postoperative hemorrhage as manifested by poor skin turgor, dry lips.
PLANNING After 8 hours of nursing intervention the patient will maintain fluid at a functional level.
INTERVENTION Change dressings frequently Provide frequent oral care Measure input and output Monitor v/s Administer IV fluids as indicated Give medications as ordered by the attending physician
RATIONALE To protect the skin and monitor lossess To prevent injury from dryness Helps maintaining fluid in the body To monitor fluids in the body To assess the patient and it serve as base line data To reduce blood loss
EVALUATION After 8 hours of nursing intervention, the patient has a normal urine output.
