Assessment

Diagnosis

Planning

Interventio
n

Subjective:
The client verbalized of pain
felt in RLQ. Pain scale of 6 over
10.

Acute pain r/t to postoperative abdominal

incision.

Short Term:
After 4 hour of
nursing intervention
the client will report
that the pain is lessen.

Perform pain
assessment each time
pain occurs. Note and
investigate changes
from previous reports

To rule out worsening of

underlying
condition/development of
complication

Have the client rate

pain intensity.

To provide a more objective

description of pain intensity.

Objective:
Facial grimace
Guarding behavior
Protective gestures
Positioning to avoid
site

Provide comfort
measures( back rub,
change of position, use
heat/cold)

Teach the postoperative client to

splint abdomen when
moving or coughing
with the pillow or rolled
bath blanket

Rationale

To promote nonpharmacologic pain

management

Splinting provide support

for the painful area
decreasing stress on
surgical site that may
increase pain, and allows
the client to participate in
coughing and deep
breathing more
comfortably.

Evaluation
Short Term:
After 4 hour of
nursing intervention
the goal met as
evidenced by the
client reported
alleviation of pain
rated by 4 on a pain
scale of 1 to 10.

Long Term:
After 1 day of
nursing intervention
the client will state
that pain has been
relieved and
controlled.

Work with client to

prevent pain. Use flow
sheet to document
pain, therapeutic
intervention, response,
length of time before
pain reoccurs. Instruct
client to report pain as
soon as it begin.

Implement strategies to
enhance effects of pain
medications, such as
relaxation techniques,
soft music, distraction,
and meditation

As timely intervention is
more likely to be successful
in alleviating pain.

Non-pharmacologic
interventions and assist in
reducing pain by affecting
the perception of pain
experience.

Long Term:
After 1 day of
nursing intervention
the client state that
pain has been
relieved and
controlled.

Assessment
Subjective:
Hindi ako makatulog as
verbalized.
Objective:
Irritable
Weak
Inability to
concentrate

Diagnosis

Planning

Disturbed sleep pattern

d/t environmental
discomforts

Short Term:
After 4 hours of
nursing intervention the
client will be able to
identify appropriate
interventions to
promote sleep and
verbalized
understanding of sleep
disturbance.

Intervention

Rationale

Determine usual sleep

pattern and
expectations

To provide comparative
baseline

Instruct client or bedpartner to keep a sleepwake log

To document symptoms
and identify factors that
are interfering with
sleep

Promote adequate
easy physical activity
during day (e.g. walking
with support of partner)

To enhance
expenditure of some
energy/release of
tension so that the
client feels ready for
sleep/rest.

Instruct in relaxation
technique/music
therapy, meditation, etc.

To decrease tension,
prepare for sleep/rest

Investigate anxious
feeling

To help determine basis

and appropriate anxiety

Evaluation
Short Term:
After 4 hours of
nursing interventions
the goal met as
evidenced by with
ability to concentrate.

reduction techniques.

Long Term:
After 2 days of
nursing intervention the
client will be able to
adjust lifestyle to
accommodate
chronobiological
rhythms, and report
improvement in
sleep/rest pattern.

Recommend quite
activities such as
reading/ listening to
soothing music in the
evening

To reduce stimulation
so client can relax

Discuss or implement
effective ageappropriate bedtime
rituals (going to bed at
same time each night,
drinking warm milk,
reading stories)

To enhance clients
ability to fall asleep,
reinforce that bed is a
place to sleep, and
promote since of
security.

Long Term:
The client was able
to formulate a plan to
adjust lifestyle that will
facilitate return to
normal sleep/rest
pattern.

Assessment
Subjective:
Medyo masakit kapag
nagagalaw at makati
yung tahi ko as
verbalized.
Objective:
With post operative
incision site.

Diagnosis
Risk for infection r/t
post-surgical site

Planning

Intervention

Rationale

Evaluation

Short Term:
After 4 hours of
nursing intervention the
client will be able to
identify the risk factors
that are present and have
a partial understanding
about infection control
procedures.

Note risk factor for

assurance of infection in
the site

To help the client to

identify the present
factors that may add up
to the infections

Observe for localized

sign of infection at
surgical site

To evaluate the
character, presence and
condition of present
infection

Short Term:
After 4 hours of
nursing interventions the
goal will be met as
evidenced of the
absence of sign and
symptoms for infection.

Make health teachings

about risk factors that
could add up on
infection

To help the client in

modifying change or
avoid some of the
factors present w/c
could reduce the
incidence of infection

Long term:
After 1 day of nursing
intervention the client will
be free from any signs
and symptoms of related
infections and display
timely wound healing.

Long Term:
The client was able
to formulate lifestyle
changes to promote
safe environment.