Nursing Ne Desired Nursing Intervention Rationale Evaluation Modification Rationale

Diagnosis # 1 ed Outcome

Acute pain P Within the 8

related to H hours of duty,
abdominal Y the patient
incision. S should be able
Subjective I to:
cues: O
L  Report INDEPENDENT
“Sakit pa pero O pain is GOAL MET. No
• EEstablish
hindi na kaayo” G relieved or To easily gain The patient modifications
rapport to the
as verbalized I controlled. cooperation form the was able to needed
patient
by the patient. C Pain patient report the
intensity 4  MMonitor Vital characteristic
Objective N to 6 will signs s of pain
cues: E decrease (location: right
 Temp: 37.5 E at 2 to 3 hypochondria
°C D from 0 to  PPerform To have baseline c region,
PR: 63 bpm 10 pain bedside care data and for scaled pain
RR: 19 cpm scale. comparison for future as 4 to 6 out
BP: 120/80 data of 0 to 10 pain
mm Hg scale, able to
 Rated pain verbalized
as 4 to 6 out  OObserve and To enhance patient’s pain felt upon
of 0 to 10 document self esteem and to pressure
pain scale. location, provide comfort to applied on the
 Pain severity and the patient site). Able to
increases character of verbalize
when pain. feeling of
moves comfort after
vigorously repositioning
 Incision site: was done.
 By getting the
Wound: dry, no following information,
discharges we are asssitting in
noted differentiating cause
of pain and providing
Dressing and information about
plaster were disease
clean and fully progression/resolutio
covered the n, development of
incision site complications and
. effective
No foul odor interventions.
noted on the
site.  PPromote This also provides an
bedrest, objective means of
allowing patient evaluating the
BACKGROUND to assume subjective experince
KNOWLEDGE: position of of the patient.
Pain is defined comfort
as unpleasant
sensory and Bedrest in low-
emotional fowler’s posiiton
experience  reduces
arising from CControl intraabdominal
actual or environment pressure; however,
potential tissue temperature patient will naturally
damage or assume least painful
described in position.
terms of such
damage.
(International
Association for Cool surrounding
the Study of aids in minimizing
Pain); sudden
or slow onset of dermal discomfort.
any intensity
from mild to  .
severe with an TTake time to listen This is helpful in
anticipated or to and maintain alleviating anxiety
predictable end frequent contact with and reducing
and a duration patient and attention which could
of greater than encourage to aid in relieving pain.
6 months. verbalize felelingf.
(Nurse’s
Pocket Guide)

The patient, Verbalization of

report pain felt feeling can reduce
at the plantar perception intensity
region of left of pain. Thus would
foot.. This facilitate in providing
affects the comfort and
ability of the relaxation.
patient to take
adequate rest
for fast
recovery. With
this, it needs
immediate
nursing
interventions to
atleast reduce
or lessen the
pain.
Nursing Diagnosis #2 Ne Desired Outcome Evaluation Nursing Rationale
Nursing
ed Interventions statement modifications
 Impaired skin
Establish rapport
integrity related to P Within the eight
Establish
Subjective: H hours of duty, the rapport Goal met. As No
Patient verbalized, “ Y client will be able evidenced by modification
Hapdos ang samad S to: verbalization needed.
sa akong tiil” I of
O understanding
Objective: L Understand the To have on the
 Temp: 37.5 °C O preventive baseline data preventive
PR: 63 bpm G measures give. Monitor vital signs and for measures
RR: 19 cpm I comparison given.
BP: 120/80 mm Hg C for future data

• Disruption of N
skin surfaces E
• Destruction of E To enhance
skin layer D patient’s self
esteem and to
Perform bedside provide
care comfort to the
patient

To determine
Inspect skin on daily unusual ties
basis and obseve and report it to
. for changes and physician for
unusualities prompt
treatment.
 Keep the area This will assist
BACKGROUND clean, carefully body’s natural
KNOWLEDGE: dress wound, process of
Skin is the body’s support incison, repair
first line of defense prevent infection
against foreign
materials that can be
considered as
injuring agents. The Demonstrated good Maintaining
appearance and the skin hygiene, e.g., clean, dry skin
skin integrity are wash thoroughly provides a
influenced by internal and pat dry carefully barrier to
factors such as infection.
genetics, age and the Patting skin
underlying history of dry instead of
the individual as well rubbing
as external factors reduces risk of
such as activity. dermal trauma
Once the skin is to fragile skin
disrupted, this will put
a person at risk since
it may become a Emphasized Improved nutrition
good medium for importance of and hydration will
bacterial growth. adequate nutrition improve skin
Post-operative and fluid intake condition
wound is closely
noted and monitored
for any unusualties To promote
since this is a risk Assist the patient in wellness.
factor that may lead understanding and
the post-operative following medical
client in acquiring regimen.
infection.
Reference: Nurse’s
Pocket Guide 11th
Editon Doenges
 Need Desired Nursing Interventions Rationale Evaluation Nursing Rationale
Outcome statement modification
s
Nursing
Diagnosis #3

Altered P Within the To easily gain

Establish rapport
Physical H entire cooperation form the
Mobility related Y rotation, patient
to pain S the client
secondary to I will be able
unhealed O to:
wound on the L
plantar region O To have baseline
Monitor vital signs
of left foot. G data and for
I comparison for future
C data
Subjective:
“Gasakit akong N To enhance patient’s
Perform bedside care
tiil kung E self esteem and to
.
maglihok-lihok E provide comfort to
ko” D the patient

Objectives: Provide different methods

So that she will be
and teachings on pain
 Temp: 37.5 knowledgeable upon the
control measures.
°C proper pain management
PR: 63 bpm technique
RR: 19 cpm
BP: 120/80 Instruct client in safety
mm Hg To prevent accidents
measuers, as
 Difficulty of that may add to the
indicated:
moving the • injury of the patient
lower Mmaintain lightning
extremities
•
Rreduce risk for falls
Background by raising the side
knowledge rails
Limitation in
independent,
purposeful Encourage active and
physical passive exercise that To increase stamina
movement of the patient can tolerate and endurance
the body or
of one or
more
extremities
Alteration in
mobility may
be a
temporary or
more
permanent
problem.
Most disease
and
rehabilitative
states involve
some degree
of immobility
(e.g., as seen
in strokes,
leg fracture,
trauma,
 morbid
obesity, and
multiple
sclerosis).
With the
longer life
expectancy
for most
Americans,
the incidence
of disease
and disability
continues to
grow. And
with shorter
hospital
stays,
patients are
being
transferred to
rehabilitation
facilities or
sent home for
physical
therapy in the
home
environment.

Reference:
Nurse’s Pocket
Guide 11th
Editon
Doenges