Ncp2
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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
ASSESSMENT
OBJECTIVE: Poor skin turgor Dry lips Weak in appearance
DIAGNOSIS
PLANNING
Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.
After 4 hours of nursing intervention patient’s pain evidenced by pain scale =7 be reduced to 3.
INTERVENTION
RATIONALE
Change the position of the patient
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 Usually altered in pain.
Provide comfort measures Assist patient in breathing techniques Provide quiet environment Relay on the patient report of pain Encourage divertional activities Monitor vital sign Administer analgesic as ordered by the AP.
After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.
To maintain acceptable level of pain.
DIAGNOSIS
PLANNING
NURSING INTERVENTION INTERVENTION RATIONALE
Fluid volume deficit related to the risk of postoperative hemorrhage.
After 8 hours of nursing intervention the patient will maintain fluid at a functional level.
Change dressings frequently Provide frequent oral care
EVALUATION
To protect the skin and monitor lossess To prevent injury from dryness
EVALUATION
After 8 hours of nursing intervention, the patient was maintained fluid as manifested by good skin turgor.
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
PLANNING
Impaired mobility related to decreased muscle strength as manifested by limited ROM.
After 8 hours of nursing intervention the patient will be able move safety and independently.
NURSING INTERVENTION 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
EVALUATION After 8 hours of nursing intervention, the patient was able to move safely and independently.
Encourage participation in self care
Enhances self concept and sense of independence
ASSESSMENT
OBJECTIVE: Poor skin turgor Dry lips Weak in appearance
DIAGNOSIS
PLANNING
Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.
After 4 hours of nursing intervention patient’s pain evidenced by pain scale =7 be reduced to 3.
INTERVENTION
RATIONALE
Change the position of the patient
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 Usually altered in pain.
Provide comfort measures Assist patient in breathing techniques Provide quiet environment Relay on the patient report of pain Encourage divertional activities Monitor vital sign Administer analgesic as ordered by the AP.
After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.
To maintain acceptable level of pain.
DIAGNOSIS
PLANNING
NURSING INTERVENTION INTERVENTION RATIONALE
Fluid volume deficit related to the risk of postoperative hemorrhage.
After 8 hours of nursing intervention the patient will maintain fluid at a functional level.
Change dressings frequently Provide frequent oral care
EVALUATION
To protect the skin and monitor lossess To prevent injury from dryness
EVALUATION
After 8 hours of nursing intervention, the patient was maintained fluid as manifested by good skin turgor.
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
PLANNING
Impaired mobility related to decreased muscle strength as manifested by limited ROM.
After 8 hours of nursing intervention the patient will be able move safety and independently.
NURSING INTERVENTION 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
EVALUATION After 8 hours of nursing intervention, the patient was able to move safely and independently.
Encourage participation in self care
Enhances self concept and sense of independence
