CUES/ EVIDENCES

(Pre)
Subjective:
Sakit kayo ng
operahan sir?
Mahadlok man ko uy,
pakatulogon rako ana?
Karun paman ko
makasulay operahan.

NURSING DIAGNOSIS
Fear/ Anxiety related
to threat of death and
pain

OBJECTIVES
At the end of our care,
our client will be able
to verbalize
understanding of
condition and
decreases fear as
evidenced by:

INTERVENTIONS
Independent:
-

a. absence of anxiety
b. Blood pressure
drops to normal range,
120/80 mmHg.

Objective:
-

Anxiety
BP: 154/96
mmHg
Respi: 25cpm
Irritable
Confusion
Lack of focus
and eye contact
Uncomfortable/
uneasy
Restlessness

RATIONALE

Ascertain what
information
client has about
diagnosis,
expected
surgical
intervention,
and future
therapies. Note
presence of
denial or
extreme anxiety.

C. Respiratory rate
improves to normal
range, 12-20 cpm.
d. absence of
irritability
e. absence of
confusion
f. Maintains focus and
eye contact
g. Comfortable, more

Explain purpose
and preparation
for diagnostic
tests.

Provides
knowledge base
for the nurse to
enable
reinforcement of
needed
information, and
helps identify
client with high
anxiety, low
capacity for
information
processing, and
needed for
special
attention.
Clear
understanding
of procedures
and what is
happening
increases
feelings of
control and
lessens anxiety.

EVALUATION
At the end of our care,
our client partially was
able to verbalize
understanding of
condition and
decreases fear as
evidenced by:
a. Blood pressure
drops to 140/90 mmHg
b. Respiratory rate
drops to 20 cpm.
c. Uncomfortability still
noted
d. Doesnt maintain
eye contact

focused

h. absence of
restlessness

Provide an
atmosphere of
concern,
openness, and
availability, as
well as privacy
for clients.

Encourage
questions and
provide time for
expressions of
fears.

Dependent:
-

Administer
anxiolitic as
ordered by the

Time and
privacy are
needed to
provide support,
discuss feelings
of anticipated
loss and other
concerns.
Therapeutic
communication
skills, open
questions,
listening, and so
forth facilitate
this process.

Provides
opportunity to
identify and
clarify
misconceptions
and offer
emotional
support.

physician.

CUES/ EVIDENCES
(Pre)
Subjective:
Sakit kayo ng
operahan sir?
Mahadlok man ko uy,
pakatulogon rako ana?
Karun paman ko
makasulay operahan.

NURSING DIAGNOSIS
Deficient Knowledge
related to lack of
exposure, unfamiliarity
with information
resources

OBJECTIVES
At the end of our care,
our client will be able
to verbalize
understanding of
condition and potential
complications as
evidenced by:

a. absence of
confusion
b. relaxed

Objective:
-

Confusion
Requesting for a
detailed
information
about the
procedure
Shows

INTERVENTIONS

RATIONALE

Independent:
-

Review effects
of surgical
procedure and
future
expectations.

Discuss
complexity of
problems
anticipated
during recovery.

c. verbalizes full
understanding of the
procedure.
d. verbalizes
understanding of
therapeutic needs.

Decreases
anxiety level.

-identify
individual
restrictions.

Provide
knowledge base
from which
client can make
informed
choices.
Physical,
emotional, and
social factors
can have a
cumulative
effect, which
may delay
recovery,
especially if
hysterectomy
was performed.
Strenuous
activity

EVALUATION
At the end of our care,
our client was able to
verbalize
understanding of
condition and potential
complications as
evidenced by:
a. Absence of
confusion
b. relaxed
c. Verbalizes full
understanding of the
procedure.
d. states that matulog
rako run para ma relax
ako kaugalingon sa
stress.

expression of
unfamiliarity
Uneasy and
looks at the OR
machines and
equipment

e. comfortable

-Review specific
pathology and
anticipated
surgical
procedure.
-

CUES/ EVIDENCES

(Intra)

Ineffective Tissue
Perfusion related to
intraoperative trauma

Objective:
-

NURSING
DIAGNOSIS

Hypovolemia
UO: 50mL
Blood loss:
300mL
Pallor
Blood pressure:
95/70 mmHg
Chills
Fatigue

OBJECTIVES

At the end of our care,

our client will be able
to demonstrate
adequate perfusion as
evidenced by:
a. stable Vital signs.

Inform client
about timely
arrival on
surgical day,
itinerary,
physician/SO
communications
.

INTERVENTIONS

Independent:
- Monitor Vital
signs, palpate
peripheral
pulses, and
note capillary
refill, assess
Urine output.

intensifies
fatigue and may
delay healing.
Provide
knowledge
base.

Logistical
information.

RATIONALE

Indicators of
adequacy of
systemic
perfusion, fluid/
blood needs,
and developing
complications.

b. Palpable pulses

At the end of our care,

our client will be able
to demonstrate
adequate perfusion as
evidenced by:
a. stable Vital signs.
b. Palpable pulses

c. Good capillary refill

d. Adequate urinary
output

EVALUATION

Assist with ROM

exercises.

Avoid use of

Stimulates
peripheral
circulation.

c. Good capillary refill

Prevent stasis

d. Blood pressure:
140/90 mmHg

knee gatch/
pillow under
knees.

e. BP within normal
range, 120/80 mmHg

of venous
circulation and
reduces risk of
thrombophlebiti
s.

f. Absence of chills
g. absence of fatigue

Assess lower
extremities for
erythema,
edema, calf
tenderness.

Collaborative:
- Administer IV
fluids, blood
products as
indicated by the
the physician.

Circulation
maybe
restricted by
some positions
used during
surgery.

Replacement of
blood losses
maintains
circulating
volume and
tissue
perfusion.

a. PLNSS fast drip

CUES/ EVIDENCES

(Intra)

Objective:

NURSING
DIAGNOSIS
Skin Integrity related
to prolonged surgical
time

OBJECTIVES

At the end of our care,

our client will be able
to prevent skin
breakdown/ injury as
evidenced by:

INTERVENTIONS

Independent:
- Inspect skin for
changes in
color, turgor,
vascularity.
Note redness,

RATIONALE

Indicates areas
of poor
circulation/
breakdown that
may lead to

e. presence of chills

EVALUATION

At the end of our care,

our client was able to
prevent skin
breakdown/ injury as
evidenced by:

Surgery lasts
for 1H and
30mins.
Unable to
change
position.
Arm ties
present
Skin is dry
Linens are not
properly
pressed
Hypovolemia

excoriation.
Observe for
ecchymosis,
purpura.

a. absence of skin
redness, trauma,
sores

b. absence of pain

c. absence of edema

Monitor
hydration
status.

d. Intact skin
e. absence of skin
excoriation

Inspect
dependent
areas for
edema.

decubitus
formation/
infection.

a. absence of skin
redness, trauma,
sores

Detects
presence of
dehydration or
overhydration
that affects
circulation and
tissue integrity
at the cellular
level.

b. absence of pain

Edematous
tissue are more
prone to
breakdown.

Maintain
patency of
drainage tubes.

Facilitates
approximation
of wound
edges.

Caution client
not to touch the
operative site.

Prevents
contamination
of area.

Reduces edema
formation that
may cause
undure

Collaborative:
- Apply ice if
appropriate.

c. absence of edema
d. Intact skin
e. absence of skin
excoriation

pressure.

CUES/ EVIDENCES
(Post)

Altered Bowel
Elimination

Subjective:
Naa koy tambal
pawala sakit dai?
Nagsugod nag sakit ug
ngotngot ako tiyan
man.

Objective:
-

NURSING DIAGNOSIS

Rated pain 8
out of 10 as 10
the highest.
Facial grimace
noted
Abdominal
guarding
Blood pressure:
145/90 mmHg
Restlessness
Pallor
Nausea and
vomiting

OBJECTIVES
At the end of our care,
our client will be able
to display active bowel
sounds/ peristaltic
activity as evidenced
by:
a. Maintains usual
pattern of elimination.
b. Pain rate decreases
from 8, as 10 the
highest.
c. Absence of pallor
d. Verbalize comfort
e. absence of
restlessness

INTERVENTIONS
Independent:
- Auscultate
bowel sounds.
Note abdominal
distention,
presence of
nausea/
vomiting.
- Assist client
with sitting on
edge of bed and
walking.
- Encourage
adequate fluid
intake,
including, fruit
juices, provide
sitz baths.
Collaborative:

RATIONALE

Restrict oral
intake as
indicated.

Maintain
nasogastric
tube if present.
Administer

f. Absence of nausea
and vomiting

Indicators of
presence/
resolution of
ileus, affecting
choice of
interventions.
Early
ambulation
helps simulate
intestinal
function and
return of
peristalsis.
Promotes softer
stool, may aid
in stimulating
peristalsis.
Prevents
nausea and
vomiting until
peristalsis
resturns. (1-2
days)
Maybe inserted
in surgery to
decompress

EVALUATION
At the end of our care,
our client was able to
display active bowel
sounds/ peristaltic
activity as evidenced
by:
a. Maintains usual
pattern of elimination
b. Absence of pallor
c. Verbalize comfort
d. absence of nausea
and vomiting

medications;
Stool softeners,
mineral oil,
laxatives, as
indicated by the
doctor.

CUES/ EVIDENCES

(Post)
Subjective:
Naa koy tambal
pawala sakit dai?
Nagsugod nag sakit ug
ngotngot ako tiyan
man.

Objective:
-

Reluctance to
attempt

NURSING
DIAGNOSIS
Impaired physical
Mobility related to
pain/ discomfort

OBJECTIVES

At the end of our care,

our patient will be able
to display willingness
to participate in
therapy as evidenced
by:

INTERVENTIONS

stomach.
Promotes
formation/
passage of
softer stool.

RATIONALE

Independent:
-

Begin passive
ROM.

a. controlled pain,
rated pain drops down
from 8, as 10 the
highest.
b. demonstrates
techniques that enable
resumption of
activities
c. Increased or

Have client
move fingers,
noting
sensations and
color of hand o

Early
postoperative
exercises are
usually started
in the first 24H
to prevent joint
stiffness that
can further limit
movement/
mobility.
Lack of
movement may
reflect problems
with the
intercostals

EVALUATION

At the end of our care,

our patient partially
was able to display
willingness to
participate in therapy
as evidenced by:
a. controlled pain
b. absence of pallor
c. limited ROM with
slight pain in the
abdominal area
d. absence of
restlessness

movement
Facial grimace
Limited ROM
Decreased
muscle mass/
strength
Restlessness
Pallor
Rated pain 8 out
of 10 as 10 the
highest.

improved strength

affected side.

brachial nerve,
and
discoloration
can indicate
impaired
circulation.

d. absence of pallor
e. performs ROM
without pain/
discomfort
f. absence of
restlessness

g. absence of facial
grimace upon moving

Help with selfcare activities

as necessary.

Assist with
ambulation and
encourage
correct posture.

Conserve
clients energy,
prevents undue
fatigue.

Client will feel

unbalanced and
may need
assistance until
accustomed to
change.

Relieves pain
and discomfort.

Collaborative:
-

Administer
analgesic as
indicated by the
physician.
a. Tramadol
50mg IVTT q 8H
x 4dose

e. Slight facial grimace

upon moving noted

CUES/ EVIDENCES

(Post)

Risk for Infection

related to presence of
surgical incision

Objective:
-

NURSING
DIAGNOSIS

Pallor
Nausea and
vomiting
Restlessness
Chills
Fatigue

OBJECTIVES

At the end of care, our

client will be able to
achieve timely healing
and free from infection
as evidenced by:
a. afebrile
b. Blood pressure
within normal range ,

INTERVENTIONS

RATIONALE

Independent:
-

Understand the
nurses role in
identifying client
at risk and
preventive
interventions.

The role of
nurses in
preventing the
spread of severe
sepsis is crucial
because they
are in the
position to

EVALUATION

At the end of care, our

client partially was
able to achieve free
from infection as
evidenced by:
a. afebrile, 36.7 C
b. Weakness

Temp: 36.7
degree Celcius

120/80 mmHg

identify clients
at the first signs
of developing
sepsis.

c. Absence of
restlessness
d. Absence of nausea
and vomiting
e. absence of severe
weakness
f. Temperature stays
within normal range.

Do proper hand
washing before
doing
intervention to
the clients
wound.

Monitor Vital
Signs.

Investigate
reports of
massive pain
out of
proportion to
visible signs.

Reduces risk of
infection.

Needed to
monitor
immunosupress
ed client.

Pressure-like
pain indicates
unstable
anesthesia.

Treat certain
infections that

Collaborative:
-

Administer
antibiotic as

c. Pain in the incisional

site
d. Restlessness
e. presence of nausea
and vomiting

ordered by the
doctor.
a. Cefuroxime 25mg
IVTT q 8H
-

CUES/ EVIDENCES

NURSING DIAGNOSIS

OBJECTIVES

Provide and
document
copious wound
irrigation; e.g.,
saline, water,
antibiotic, or
antiseptic.

INTERVENTIONS

caused from
bacteria.

Maybe used to
reduced
bacterial counts
at surgical site
and cleanse the
wound of debris.

RATIONALE

EVALUATION

(Intra)
Objective:
-

Operating room
has small area
Operating room
was crowded
Equipment were
located near to
her
Hand restraints
were noted

Risk for Injury related

to structure of
environment and
exposure to equipment

At the end of care, our

client will be able to be
free from injury as
evidenced by:
a. absence of skin
trauma
b. equipment that can
cause harm are away

Independent:
- Remove
dentures, partial
plates or
bridges,
preoperatively
per protocol.
-

c. absence of
restraints
d. fewer people
accumulates the room

Foreign bodies
maybe
aspirated during
the operation.

Contact lenses
may cause
corneal
abrasions while
under
anesthesia.

Remove
prosthetics,
other devices
preoperatively
or after
induction.

Remove
jewelries.

Verify client
identity and
scheduled
operative
procedures by
comparing client
chart and
surgical
schedule.

Document
allergies

At the end of care, our

client partially was
able to achieve free
from infection as
evidenced by:
a. afebrile, 36.7 C
b. Weakness
c. Pain in the incisional
site
d. Restlessness

Metals conduct
electrical
current and
provide an
electro-cautery
hazard.
Ensures correct
client,
procedure and
appropriate site
to operate.

Reduce risk for

allergic
responses that

e. presence of nausea
and vomiting

including for risk

for adverse
reaction o latex,
tape and prep
solutions.

CUES/ EVIDENCES
(Pre)
Subjective:
Nagool jud pud ko
kay dili najud ko
kaanak tungod ani.

NURSING DIAGNOSIS

OBJECTIVES

Situational Low SelfEsteem related to

the loss of her body
part/ femininity

At the end of our care,

our client will be able
to improve or adapt
body/ self changes as
evidenced by:

INTERVENTIONS

Objectives:
- Anxiety
- Depression
- Crying noted
- Doesnt maintain eye
contact

RATIONALE

Independent:

a. Verbalize concerns
and indicate healthy
ways of dealing with
them.
b. Verbalize
acceptance of self in
situation and
adaptation to change
in body/ self image.

may impair skin

integrity or lead
to life
threatening
systemic
reactions.

Provide time to
listen to
concerns and
fears of client.
Discuss clients
perception of
self related to
anticipated
changes and her
specific lifestyle.

Provide accurate
information,
reinforcing
information
previously given.
Ascertain

Research
supports the
idea that
hysterectomy is
physiologically
and
psychologically
stressful for a
woman, even
when she desires
the procedure.

Provide
opportunity for
client to
question and
assimilate
information.

EVALUATION
At the end of our care,
our client was not able
to improve or adapt
body/ self changes as
evidenced by:
a. presence of
depression
b. shows weakness
and lack of interest to
any discussion
c. doesnt maintain
eye contact when
asked
d. speak minimally

individual
strengths and
identify previous
positive coping
behaviors.
-

Provide open
environment for
client to discuss
concerns about
sexuality.

Helpful to build
on strengths
already available
for client to use
in coping with
current situation.

Promotes
sharing of
beliefs/ values
about sensitive
subject, and
identifies
misconceptions/
myths that may
interfere with
adjustment to
situation.

May need
additional help
to resolve
feelings about
loss.

Collaborative:
-

Refer to
psychiatric
clinical nurse
specialist, other
professionals for
counseling as
necessary.

E. SUMMARY OF NURSING DIAGNOSIS

Preoperative
Fear/ Anxiety related to threat of death and pain
Deficient Knowledge related to lack of exposure, unfamiliarity with information resources

Situational Low Self-Esteem related to the loss of her body part/ femininity

Intraoperative
Risk for Injury related to structure of environment and exposure to equipment
Skin Integrity related to prolonged surgical time
Ineffective Tissue Perfusion related to intraoperative trauma

Postoperative

 Impaired physical Mobility related to pain/ discomfort

Risk for Infection related to presence of surgical incision
Altered Bowel Elimination