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Assessment

Subjective Medyo nalulungkot ako dahil sa kalagayan ko ngayon As verbalized by the client. Objective Pt.is conscious and coherent. (+) irritability Restlessness Frequent urination Flushing pacing V/S taken as follows: B.P130/90mmH g P.R.110bpm R.R.-23cpm T.-37 C

Diagnosis
Anxiety related to change in health status and associated changes in role function.

Inference

Planning
After 8 hrs. of nursing care, the client will appear relaxed and the level of anxiety is reduced.

Intervention
Independent Assess patients coping mechanisms in handling anxiety. Acknowledge awareness of pt.s anxiety. Encourage pt. to talk about anxious feelings and examine the anxiety, provoking situation. Dependent Administer anti anxiety med. As ordered.

Rationale
Independent: This assessment helps determine the effectiveness of coping strategies currently used by pt. Acknowledge ment of pt.s feeling and validates the feelings and communicates acceptance of those feelings. Recognize level of anxiety. Dependent To lessen excitement, nervousness and irritation.

Evaluation
After of 3 hrs. nursing care, the client was relaxed and the level of anxiety was reduced. serene

Change in health status

Worried in his limitation (e.g.activity, diet, role)

Anxiety

Assessment
Subjective Medyo mahapdi at parang namamanhid yung parte malapit sa tahi ko, as verbalized by the patient. Objective Conscious and coherent. Poor skin turgor. Dry skin (+) redness, swelling around the incision site. With ongoing IVF of # 4 D5NM 1L X 12, infusing well. With ongoing side drip of # 8 D5W 90cc + 100cc Nicardipine X 2mg/hr at 45cclevel, infusing well.

Diagnosis
Impaired skin integrity related to post operative surgical incision.

Inference
Surgical site Disruption of skin surface

Planning
After 4 hrs. of continuous nursing care intervention, the client will describe measures to protect and heal the skin and to care for any skin lesion.

Intervention
Independent: Assessed the surgical site. Individualize plan according to the client's skin condition, needs, and preferences. Teach the client why a topical treatment has been selected. Dependent: Vit. C, protein rich foods for diet as ordered.

Rationale
Independent: To know the extent of care. Avoid harsh cleansing agents, hot water, extreme friction or force,or cleansing too frequently. The type of dressing needed may change over time as the wound heals or deteriorate. Dependent: For wound healing.

Evaluation
After 4 hrs. of continuous nursing care intervention, the client described measures to protect and heal the skin and to care for any skin lesion

Skin integrity impaired.

Assessment
Subjective Masakit po ang tahi ko, as verbalized by the patient. Objective Pt. is conscious, self-focusing Guarding behavior Facial grimace Restlessness. Reported a pain scale of 6 out of 10. With ongoing IVF of # 4 D5NM 1L X 12, infusing well. With ongoing side drip of # 8 D5W 90cc + 100cc Nicardipine X 2mg/hr at 45cclevel, infusing well. V/S taken as follows: B.P. -140/100

Diagnosis Inference
Acute pain related to post-op surgical incision Surgical incision

Planning
After 8hrs. Of nursing care, the patients pain will be decreased from 6/10 to 3/10.

Intervention
Independent: V/S taken and recorded. Assessed location of pain, severity and character of pain. Provide rest periods to facilitate comfort, sleep and relaxation. Provide calm and quite environment. Instruct patient to report pain. Dependent: Administered medications as prescribed such as Anticholenergics and narcotics.

Rationale
Independent: To gathet baseline data. Assist in differentiating cause of pain. The patients experiences of pain may become exaggerated as result of fatigue. To facilitate resting environment So that relief measures may be instituted. Independent: Helps to relieve pain.

Evaluation
After 8hrs. of nursingcare, the patients pain was decreased from 6/10 to 3/10.

A-Delta myelinated fibers stimulate sharp pain when noxious mechanical stimuli

Pain will be transmitted to

Pain will be perceived by the hypothalamus.

PR.-125 R.R.-32 T.- 38.2 Has a sharp, gradual onset of pain and has a pain scale of 6 to 10 that persist when moving.

Assessment
Subjective Nawawalan na ako ng ganang kumain As verbalized by the client. Objective Weight of Decrease appetite Anxious Fatigue With ongoing IVF of # 4 D5NM 1L X 12, infusing well. With ongoing side drip of # 8 D5W 90cc + 100cc Nicardipine X 2mg/hr at 45cclevel, infusing well.

Diagnosis
Imbalance nutrition: Less than body requirement related to decrease intake of food.

Inference

Planning
After 2 days of continuous nursing care intervention, the client will increase intake of food.

Intervention
Independent: Monitor or explore attitudes toward eating and food. Assist pt. with meals as needed. Ensure a pleasant environment, a facilitative position and good oral hygiene and dentition. Discourage beverages that are caffeinated and carbonated. Dependent: Consult dietitian for further assessment and recommendations regarding food preferences and nutritional support.

Rationale
Independent: Many psychological,ps ychosocial, and cultural factors determine the type, amount, and appropriateness of food consumed. HOB elevated 30 degrees aids in swallowing. May decrease appetite and lead to early satiety. Dependent: Dietitians have a greater understanding of the nutritional value of foods and may be helpful in assessing specific ethnic or cultural foods.

Evaluation
After 2 days of continuous nursing care intervention, the client will increase intake of food.

Decrease intake of food.

Inadequate nutrients in the body.

Nutritional Imbalance

Assessment

Diagnosis Diagnosis

Inference Inference

Planning Planning
Within 2 hrs. Within 8 hrs. of of continuous continuous nursing nursing care, the care, the client will client freedom manifestwill verbalize from infection as understanding manifested by: of desired content, Afebrile and/or performs (-) signs of desired skill. inflammation.

Intervention Intervention
Independent: Independent: Provide V.S. taken physical and recorded. comfort the Assessed for the learner. surgical site. Establish Assisted in objectives positioning and goals for every 2 hrs. learning at the Position client beginning of lying on the the session. unaffected side. Explore attitudes and Performed feelings about wound care. changes. Kept the site clean and dry. Allow for and support Dependent: selfdirected, self Medication designed given as learning. ordered. Provide information using various medium Encourage repetition of information or new skill. Provide positive, constructive reinforcement of learning. Document progress of Intervention teaching and learning.
Independent: Monitored vital signs; Palpated peripheral pulses, assessed capillary refill, mucous

Rationale Rationale

Evaluation Evaluation

Subjective: Deficit Lack of primary Risk for Infection, Inadequatecognitive knowledge information. Objective: ang inadequate defenses bakit related to New >Redness, bawal primary defenses daming swelling relatedcondition and to post op kainin? treatment. around the surgical incision. Limited knowledge incision site Invasion of Objective: about the present >Chilling pathogens Questioning condition and >Cold, clamy the health function. skincare member. >Pale looking Verbalizing >Febrile Infection inaccurate >With ongoing information. Knowledge deficit. IVFIncorrect task of # 4 D5NM 1L X performed. 12, infusing Expressing well. confusing >With ongoing when sideperforming drip of # 8 D5W 90cc + task. 100cc Nicardipine X 2mg/hr at 45cclevel, infusing well. >V/S taken as follows: B.P. -110/80 PR.-94 R.R.-19 T.- 37.5

Assessment
Subjective: Nauuh aw ako lagi, as verbalized by the patient. Objective: excessiv

Diagnosis
Fluid Volume Deficit, excessive fluid loss related to wound drainage.

Inference
Abnormal wound drainage Loss of body fluid

Planning
Within 8 hrs. of continuous nursing care, the client will; maintain adequate fluid volume as evidenced by: vital signs

Within hrs. of Within 88hrs. of continuous continuous This allows Provides nursing care, the nursing care, the patient data. baselineto client was concentrate on client manifested verbalized what is being freedom from Avoid understanding of infection as discussed infection toor desired content, demonstrated. manifested by: the site. and/or performs According To provide to Afebrile desired skill. Maslows Laboratory good blood theory, basic Reports circulation and physiological within normal prevent other needs must be range. complication addressed (-) signs of such as bed before sores. patient inflammation. education. Prevent wound This allows learner to infection. know what Moisture will be attracts discussed microbes. and expected Helps to during the prevent session. infection such Adults tend to as Antibiotic. focus on hereand-now, problemcentered education. This assists the nurse in understanding how learner may respond to the information Rationale Evaluation and possibly how successful the Within 8 hrs. of continuous nursing To patient may be care, the client was; document any with the changes. expected noted changes maintained changes. in body adequate fluid temperature. Adults learn volume Observed forfeel as evidenced when they postural by: they are

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