Вы находитесь на странице: 1из 8

NURSING PRIORITIZATION NURSING DIAGNOSES Acute pain related to surgical incision as evidenced by guarding behavior, facial grimace, irritability,

restlessness and pain scale of 6/10. S: As verbalized by the client. O: >guarding behavior >facial grimace >irritability >restlessness >pain scale of 7/10 CUES RANK 1 JUSTIFICATION This should be prioritized first because under Maslows hierarchy of needs, pain avoidance is under the physiologic needs which are the basic need of man. And also, if we correct this problem we may also correct impaired physical mobility, impaired walking, and self care deficit, because all of these problems are caused by the pain felt by the client. Risk for infection related to surgical incision on abdomen. O: Vertical incision on midline of the abdomen due to recent Appendectomy 3 This should be given priority because the client has undergone a major surgery therefore his immune system is altered so we should focus on the prevention of infection. Disturbed sleeping patterns related to sleep interruptions for therapeutics, monitoring and other S: Paputol-putol yung tulog ko kasi mayat maya may dumadaan eh. 2 This should be 2nd because sleep and rest is under the physiologic needs of man, which are basic for

generate awakening and excessive environmental stimulation (like noise and lighting).

As verbalized by the client. O: >presence of eye bags >irritability >weakness

us to survive. And enough rest is good for the clients recovery from operation.

Self care deficit (bathing and hygiene) related to muscle weakness secondary to recent surgical incision on abdomen as evidenced by slight body odor.

O: >slight body odor

This should be prioritized 4th because the client may resume daily self care activities if he has regained his strength by sleeping and absence of pain.

NURSING CARE PLAN ASSESSMENT NURSING DIAGNOSIS S: Kumikirot pa yung sugat ko . As verbalized by the client. Acute pain related to surgical incision as evidenced by guarding behavior, facial grimace, irritability, restlessness and pain scale of 6/10. After 12 hrs of nursing intervention the client will be able to report pain has lessened from 6/10 to 2/10. >Provide comfortable >Calm environment After 12 hrs of nursing Long term Goal Independent Goal met PLANNING INTERVENTION RATIONALE EVALUATION

environment

like helps decrease anxiety intervention the client the patient and was able to report pain

changing bed linens of and tuning on the fan

promote likelihood of had lessened from decreasing pain. p.368 6/10 to 2/10

O: >guarding behavior >facial grimace >irritability >restlessness >pain scale of 6/10 >After 1 hour of nursing intervention the client will be able to verbalize methods that provides relief from pain Short term Goal

Nurses Pocket Guide As evidenced by: 9th edition(F.A Davis company) >absence of

>Instruct to put binder >To protect the area of restlessness, on the abdomen. incision and to improve irritability, and comfort. p.368 Nurses guarding behavior. Pocket Guide 9th >less facial grimace Davis Short term Goal pulmonary Goal met especially >After 1 hour of

edition(F.A company) >Instruct patient to do >For

>After 2 hours of nursing intervention the client will be able to demonstrate use of relaxation skills and diversional activities to alleviate pain.

deep

breathing

and ventilation

coughing exercise.

when exercising and to nursing intervention relieve stress and the client was able to verbalize methods that 7th pain

promote relaxation.

p.229 Fundamentals of provides relief from Nursing edition) >Provide diversionary >To activities, initiate ankle circulation, pumping, active lower venous promote Goal met prevent >After 2 hours of and nursing intervention (Kozier

stasis

extremity ROM, and prevent pressure on the client was able to walking. the operative site. demonstrate use of

p.368 Nurses Pocket relaxation skills and Guide 9th edition(F.A diversional activities to Davis company) Dependent >Administer analgesics as per doctors order. >Relieves pain felt by the patient. p.369 Nurses Pocket Guide 9th edition(F.A Davis company) alleviate pain.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

S: Paputol-putol yung tulog ko kasi mayat maya may dumadaan eh. As verbalized by the client.

Disturbed sleeping patterns related to sleep interruptions for therapeutics, monitoring and other generate awakening and excessive environmental

Long term Goal

Independent

Long term Goal Goal met

After 1-2 days of nursing intervention the client will be able to report increase sense of well being and feeling rested.

>provide quiet environment and comfort measures such as back rub, washing hands and face and straightening

>to promote relaxation After 1-2 days of to the client and to nursing intervention initiate sleep. p.1124 the client was able to Fundamentals Nursing edition) (Kozier of report increase sense 7th of well being and feeling rested.

O: >presence of eye bags >irritability >weakness >yawning

stimulation (like noise and lighting). Short term Goal

of bed linens as preparations for sleep. >recommend limiting After 1 hour of nursing intervention the client will be able to verbalize understanding of sleep disturbance. >Do as much care as >To possible After 2 hours of nursing intervention the client will be able to identify and demonstrate appropriate interventions to promote sleep. >Explain necessity of disturbances for monitoring Vital Signs and care when hospitalized without disturbances and avoid during Goal met also to After 2 hours of of inducing caffeine containing foods especially before bed time. >caffeine mental Short term Goal causes Goal met alertness. After 1 hour of nursing

p.1126 Fundamentals intervention the client of Nursing (Kozier 7th was able to verbalize edition) understanding of sleep disturbance.

waking up the client sleep,

and do as much care maximize

the

sleep nursing intervention

as possible while the and rest of the client. the client was able to client is still awake. p.1125 Fundamentals identify and of Nursing (Kozier 7th demonstrate edition) appropriate

>For the patient to interventions to have an understanding promote sleep. of the importance of care being done to her and to minimize the complaint. p.1125

Fundamentals Nursing edition) (Kozier

of 7th

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

O: Vertical incision on midline of abdomen due to recent surgical procedure

Risk for infection related to surgical incision on abdomen.

Long term goal After 2-3 days of nursing intervention the patient will achieve timely healing of wound and be free from infection.

>cleanse incision site daily with appropriate solution/according to hospital policy.

>to ensure clean

Long term Goal

incision site, to prevent Goal met contamination. p860 Fundamentals of Nursing(Kozier 7 edition)
th

After 2-3 days of nursing intervention the patient had achieved timely healing of wound and free from infection.

>encourage early ambulation, deep

>for mobilization of respiratory secretions. p.308 Nurses Pocket Guide 9th edition(F.A Davis company)

Short term Goal After nursing 4 hours

breathing and position of change.

Short term Goal Goal met After 4 hours of

intervention

the patient will be able to understand >monitor white blood >rising WBC indicates

nursing

intervention

causative identify

factors, cell count signs of

bodys efforts to combat pathogens. Normal values: 4000 to 11000 mm3. p861 Fundamentals of Nursing(Kozier 7th edition)

the patient was able to understand causative

infections and report them to the health care provider accordingly.

factors, identify signs of infections and report them to the health care provider accordingly.

>monitor elevated temperature, redness, swelling, increased pain, or purulent drainage at incision.

>these are signs of infection. p861 Fundamentals of Nursing(Kozier 7th edition)

>wash hands before contact with patient before procedures

>friction from running water effectively removes microorganisms from hands. Washing between procedures reduces risk of transmitting pathogens

from one area to another. p644 Fundamentals of Nursing(Kozier 7th edition) Dependent >administer antibiotics >antibiotics combat pathogens. p.308 Nurses Pocket Guide 9th edition(F.A Davis company)

Похожие интересы