NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

RATIONALE

Subjective: Sexual Due to the Short term: > Obtain sexual >To maximize Short term:
patient may Dysfunction altered body After 8 hours of history including usual communication and After 8 hours of
verbalized: related to structure done nursing patterns of functioning understanding nursing
altered body by the removal interventions the and level of desires interventions,
-problem such as structure and of the parts of patient will identify The patient
loss of sexual function the sexual organ stressors in lifestyle identified
desire it results to loss that may contribute stressors in
of sexual desire to the dysfunction > Be alert to comments >Sexual concerns are lifestyle that
- inability to and satisfaction of client often disguised as contributes to
achieved desired humor, sarcasm, or the dysfunction
satisfaction offhand remarks
Long term: Long term:
-conflicts involving
values After 3 day of The patient
nursing > identify current > These factors may be verbalized
interventions the stressors in individual producing enough understanding
patients will situations anxiety to cause of individual
Objective: verbalize depression reasons for
understanding of sexual problems
-alteration in individual reasons
relationship with for sexual problems
SO > Avoid making value > They do not help the
judgments client
-Change of interest
in self and others

>Establish therapeutic >To promote treatment

nurse-client relationship and facilitate sharing of
 sensitive information
>Provide ways to obtain
privacy
>To allow sexual
expression for
individual between
partners without
embarrassment.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSI SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

S RATIONALE

Subjective: Risk for Due to the Short term: Note risk factors for To evaluate presence/ Short term:
infection incision made After 8 hours of After 8 hours of
occurrence of infection character of infection
secondary to in the body nursing interventions, nursing
Objective: surgical there are a the patient shall interventions, the
incision chance that identify and patient identified
-Weakness foreign body demonstrate and demonstrate
will enter the intervention to Observed for localized To evaluate presence intervention to
-Pallor incision site that prevent infection prevent infection
sign of infection at character of infection
would cause the
-with dry and intact infection surgical incisions or Long term:
dressing on the area. wounds
Long term: The patient
-Pain over the doesn’t
incision After 1 day of Administer and instruct To determine experience
nursing interventions, infection
the patient will not precautions regarding effectiveness of
-Irritability
have infection medication regimen and therapy and if there is
-Presence of intact note clients response a presence of side
dressing
effect.
-Impaired physical
mobility
Emphasize necessity of To inform the client
taking antibiotics, as the risk of
directed discontinuation of
treatment
 Review environmental To assess if there is a
factors need of avoidance or
modification of
environment to
reduce incidence of
infection

Note risks factors for Increase awareness

of potential
occurrence of infections(
complications.
e.g., compromised host,
skin integrity,
environmental
exposure )

Note signs and Increase awareness

symptoms of sepsis of potential
( fever, chills, complications
diaphoresis, altered level
of consciousness,

NURSING CARE PLAN

 ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
RATIONALE

Subjective: Acute pain Due to the Short term: 1. Monitor/document Variation of Short term:
The patient secondary to incision made After 8 hours of After 8 hours of
characteristics of pain, appearance and
verbalized: surgical in the body nursing interventions, nursing
operation during the the patient’s pain noting verbal reports, behavior of patients interventions,
“ di ako masyado operation there scale will decrease The patient’s
nonverbal cues (e.g., in pain may present a
makagalaw kasi is a presence of 8/10 to 3/10 pain scale
masakit yung tahi pain. moaning, crying, challenge in decreased 8/10
sa tiyan ko” Long term: to 3/10
restlessness, diaphoresis, assessment. Most
Objective: After 1 day of clutching chest, rapid patients with an acute Long term:
nursing interventions, breathing), and MI appear ill,
-irritability patient’s pain will The patient’s
diminish and perform hemodynamic response distracted, and pain diminished
-impaired physical activities like side (bp/heart rate changes). focused on pain. and performed
mobility movement and leg activities like
bending Verbal history and side movements
-disturbed sleep deeper investigation and leg bending
pattern
of precipitating
-restlessness factors should be
postponed until pain
-facial grimaces
is relieved.
Respirations may be
increased as a result
of pain and
associated anxiety;
release of stress-
 induced
catecholamines
increases heart rate
and BP.

2. Obtain full description Pain is a subjective

of pain from patient experience and must
including location, be described by
intensity (0–10), patient. Provides
duration, characteristics baseline for
(dull/crushing), and comparison to aid in
radiation. Assist patient determining
to quantify pain by effectiveness of
comparing it to other therapy,
experiences resolution/progressio
n of problem.

3. Instruct patient to Delay in reporting

report pain immediately. pain hinders pain
relief/may requires
increased dosage of
medication to
 achieve relief. In
addition, severe pain
may induce shock by
stimulating the
sympathetic nervous
system, thereby
creating further
damage and
interfering with
diagnostics and relief
of pain.

4. Provide quiet Decreases external

environment, calm stimuli, which may
activities, and comfort aggravate anxiety
measures (e.g., and cardiac strain,
dry/wrinkle-free linens, limit coping abilities
backrub). Approach and adjustment to
patient calmly and current situation.
confidently.

5. Assist/instruct in Helpful in decreasing

relaxation techniques, perception of/
e.g., deep/slow response to pain.
breathing, distraction Provides a sense of
behaviors, visualization, having some control
guided imagery. over the situation,
increase in positive
attitude.

6. Keep at rest in semi Gravity localizes

fowler’s position. inflammatory
exudates into lower
abdomen or pelvis,
relieving abdominal
tension, which is
accentuated by
supine position.

7. Encourage deep Deep breathing

breathing. exercises is believed
to reduce pain by
expanding the lungs,
thus increasing the
oxygen intake of the
body and increasing
 the circulation of
blood.

8. Provide diversion Refocuses attention,

activities. promotes relaxation,
and may enhance
coping abilities.

9. Check vital signs Important second-

before and after each line agents for pain
intervention. control through effect
of blocking
sympathetic
stimulation, thereby
reducing heart rate,
systolic BP, and
myocardial oxygen
demand. May be
given alone or with
nitrates. Note: beta-
blockers may be
contraindicated if
myocardial
contractility is
severely impaired,
because negative
inotropic properties
can further reduce
contractility.