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