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NURSING CARE PLAN

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS
Subjective data: ACTIVITY Intestinal LONG TERM Independent
 “Medyo INTOLERANCE obstruction GOAL:
nahihirapan RELATED TO ↓ • Establish • Rapport is
akong SURGICAL Pain in the After 2 days of rapport important After 2 days of
gumalaw PROCEDURE AS abdomen nursing to gain nursing
dahil sa MANIFESTED BY ↓ interventions the patient’s interventions the
opreasyon LIMITED MOBILITY Exlap client will be cooperati client :
ko.” as ON THE LOWER ↓ able to : on and • was able to
verbalized EXTREMITIES Surgical Incision • Maintain reduce maintain
by the client ↓ activity anxiety. activity
Start of the level level like
Objective data: inflammatory within • Monitor vital • Baseline moving in a
process capabiliti signs data is light way
 Facial ↓ es. important and asking
grimace when PAIN to help help in the
trying to move ↓ determine significant
 VS: Pain upon moving patient’s others when
o T: 36.6 ↓ current trying to
°C Limited mobility health ambulate or
o P: 80 ↓ status and move.
bpm ACTIVITY evaluate
o R: 18 INTOLERANCE efficacy
cpm of nursing
o BP: interventi
110/80 on
mmHg rendered.

 Pain scale of • Establish • Motivatio


6 (moderate) guidelines and n is

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out of 10 goals of activity enhanced
with the patient if the
 guarded and caregiver. patient
movement participat
when moving es in goal
setting.

• Encourage • Rest
adequate rest between
periods, especially activities
before meals, other provides
ADLs, exercise time for
sessions, and energy
ambulation. conservati
on and
recovery.

• Encourage • Acknowle
verbalization of dgment
feelings regarding that living
limitations with
activity
intoleranc
e is both
physically
and
emotional
ly
difficult
aids
coping.

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• Maintain a • Promotes
quiet, comfortable rest and
environment sleep and
prevents
anxiety
thereby
decreasin
g the
patient’s
oxygen
demands

• Teach • This
patient/caregiv promotes
ers to awareness
recognize signs of when
of physical to reduce
over activity. activity.

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