Apos ASSESSMENT DIAGNOSIS PLAN INTERVENTION RATIONLALE EVALUATION

Subjective: Acute Pain The Patient will INDEPENDENT: The patient reported relief in
“masakit, aray related to report relief Gravity localized inflammatory pain and appeared relaxed.
(pointing to his presence of and will appear Keep at rest in exudates into lower abdomen,
abdomen )” as surgical incision relaxed within Semi-Fowler’s relieving abdominal tension which
verbalized by the as evidenced by one hour. position is accentuated by supine position.
patient. report of pain
and facial
Objective: grimace.
Refocuses attention promotes
• PAIN SCALE: 9 relaxation and may enhance
Provide Diversional coping abilities.
• Facial grimace activities.

• Stabbing Pain
in the COLLABORATIVE: Relief pain facilitates cooperation.
postoperative
site that can be Administer analgesic
felt most as indicated by the
especially physician.
when touch
and with
minimal
movement
 ASSESSMENT DIAGNOSIS PLAN INTERVENTION RATIONLALE EVALUATION

Subjective: Impaired skin Client will INDEPENDENT: Protects wound from mechanical Client achieved a timely
integrity as achieve a Reinforce initial injury and contamination. wound healing within
Objective: evidence by timely wound dressing/change as hospitalization period.
disruption of healing within indicated. Use strict
• striae skin layers and hospitalization aseptic techniques.
gravidarium tissue period. Avoid risk for skin trauma and
Gently remove tape disruption of wounds.
• scarring in and dressing when
the changing.
abdomen Prevent tape skin abrasions.
due to Check tension of Wrapping tape can
previous cs dressings. Apply impair/occlude circulation t
tape at center of wound and to distal portion of
• wound from incision to outer extremity.
sutures margin of dressing,
Avoid wrapping
tape around
extremities.
Early recognition of delayed
Inspect incision healing/developing
regularly, noting complications may prevent a
characteristics and more serious situation.
integrity. Note for
delayed healing
and complications.
Prevent contamination of area.
Caution client not to
touch incision.

COLLABORATIVE:
Reduce edema formation.
Apply ice if
appropriate.
Provides additional support for
Use abdominal high-risk incision.
binder if indicated.
 ASSESSMENT DIAGNOSIS PLAN INTERVENTION RATIONLALE EVALUATION

Subjective: Innefective role Within 4hrs. of Assess client role in Help to know client’s The patient verbalized realistic
“hindi ko alam kung sino performance nursing family constellation. responsibilities and how illness perception and acceptance of
nag-aasikaso sa possibly intervention the Identify concerns affects this role. self change role.
pamilya ko, sana evidence by patient will about role
gumaling na agad ang delay in physical verbalize dysfunction/
sugat ko” as verbalized capacity to realistic interruption.
by the patient resume role perception and
acceptance of Assess level of
Objective: self change anxiety, clients’ Information provides baseline for
role. perception of degree identifying/individualizing plan of
• restlessness of threat to self/life. care.

• irritability Motivate positive

attitude towards
• poverty of client, providing Helps client changes that are
speech opportunities for occurring and begin to realize that
client to exercise control over self/situation is
control as much as possible
possible.

Assist client to
develop strategies Planning for changes that may
for dealing changes. occur/be required promotes sense
of control and accomplishment
without loss of self esteem.