Post-operative

CUES NURSING RATIONALE OBJECTIVE NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective: PAIN A disruption SHORT DEPENDENT: SHORT

“Medyo (ACUTE) in tissue TERM Administer analgesics as Relief of moderate to TERM GOAL:

masakit layer may GOAL: ordered: severe pain. After 15-30

yung sugat Related to cause a After 15-30 • Nubain 1/2cc IVT q minutes of

ko kaya hindi surgical decrease minutes of 4 PRN nursing

rin ako incision supply of nursing INDEPENDENT: interventions,

masyadong oxygen due interventions, Noted patient’s age, Approach to the patient

makakilos. As to decrease the patient coexisting medical/ postoperative pain reported pain

Since may manifested blood will report psychological conditions, management is based was

gamot by supply. control of idiosyncratic sensitivity on multiple variable controlled as

naman kaya When blood pain as would to analgesics and factors. evidence by

ko naman.” Subjective: flow to a be intraoperative relaxed

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 “Medyo tissue often manifested course(e.g., size/ appearance,

Pain Scale masakit becomes by relaxed location, drain absence of

of 5 out of 10 yung sugat very painful appearance, placement, anesthetic guarding

ko kaya hindi within a few absence of agents used). Provides information behavior and

Legend: rin ako minutes. guarding and Evaluated pain regularly about need for/ a decrease

0 – absence masyadong a decreased (e.g., every 2hours x 12) effectiveness of level of pain

of pain makakilos. level of pain noting characteristics, interventions. to a scale of

1 – 3 –mild Since may Reference: scale of less locations and intensity

pain gamot Medical than 5 (0-10 scale). It may not always be

4–6– naman kaya Physiology Emphasize patient’s possible to eliminate

moderate ko naman.” By: Arthur C. LONG TERM responsibility for pain; however,

pain Guyton GOAL: reporting pain/ relief of analgesics should

7 – 10 – 11th Edition After 2 days pain completely. reduce pain to a

severe pain Objective: page 599 of nursing tolerable level. A

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 -grimacing interventions, frontal and/or occipital

Objective: -guarding the patient headache may develop LONG TERM

-grimacing behavior(RU will have 24-72 hours following GOAL:

-guarding Q) absence of spinal anesthesia, UNABLE TO

behavior(RU pain as would necessitating RENDER

Q) be recumbent position, DUE TO

manifested increased fluid intake TIME

by relaxed and notification of the CONSTRAIN

appearance anesthesiologist. TS (Ms. MD is

and Assessed vital signs, Changes in these vital discharged

restfulness, noting tachycardia, signs often indicate already)

absence of hypertension and acute pain and

guarding increased respiration discomfort. Note: some

behavior and even if patient denies of patients may have a

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irritability, pain. slightly lowered BP,

pain scale at which returns to

0. normal range after pain

relief is achieved

Assessed causes of Discomfort can be

possible discomfort caused/ aggravated by

other than operative presence of nonpatent

procedure. indwelling catheters,

NG tube, parenteral

lines (bladder pain,

gastric fluids and gas

accumulation and

infiltration of IV fluids/

medications.) May

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 relieve pain and

enhance circulation.

Reposition the client in Semi-fowlers position

semi-fowler’s. relieves abdominal

muscle tension,

Improves circulation,

reduces muscle

tension and anxiety

associated with pain.

Provided backrub, Enhances sense of

heat/cold applications as well-being

additional comfort

measures

Encouraged use of Relieves muscle and

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 deep-breathing emotional tension;

exercises, guided enhances sense of

imagery, visualization, control and may

music. improve coping

abilities.

CUES NURSING RATIONALE NURSING NURSING RATIONALE EVALUTION

DIAGNOSIS OBJECTIVES INTERVENTIONS

OBJECTIVE: Problem: If people may not SHORT TERM: INDEPENDENT: SHORT TERM:

Activity have the After 1 day of After 1 day of

- Slowed Intolerance motivation or nursing intervention, Adjust activities or To prevent nursing

movement energy to perform the client will be things that will be over exertion. intervention, the

- Body Etiology: activity some able to participate convenient to the patient

malaise R/T clients who willingly in patient such as participated

generalized undergone necessary activities letting her things willingly in

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SUBJECTIV weakness surgery, client as would be further she needed be at necessary

E: may experience evidenced by her bedside such activities as

“Medyo Signs and more fatigue and increased as her phone, evidenced by

nanghihina Symptoms: weakness that movement/activities tissue water and moderate

pa ako, hindi As are unable to by the client, as etc. movement as

pa ako manifested perform the task. verbalized by the Reduce intensity To assist client the client

masyadong by client, “Syempre level of activities. with verbalized,

makakilos.” OBJECTIVES Reference: may anesthesia na contributing “Eto, tnatry ko

: Medical – binigay sakin di ba, factors and naman tumayo

-Pallor Surgical 4th eto, medyo manages mag –isa. So

- Slowed Edition vol.1 nanghihina pa ako activities within far kaya

movement Joyce M. Black kaya kailangan ko individual limit. naman,

- Body and Esther pa ng mag-aalalay Increase exercise To assist client humahawak

malaise Matassarin sa akin for the mean or activity level to rearrange ako sa bed.”

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 Jacobs p.440 time.” gradually; Teach activities within

SUBJECTIVE method to individual LONG TERM:

S: Fundamentals of LONG TERM: conserve energy, limits. UNABLE TO

“Medyo Nursing 5th Edition After 2 days of such as stopping RENDER

nanghihina Barbara Kozier, nursing intervention, for a minute to INTERVENTIO

pa ako, hindi Glenora Erb, the client will be take a rest when N DUE TO

pa ako Audrey Berman, able to demonstrate walking. TIME

masyadong Shirlee Snyder increase in activity Promote comfort To enhance CONSTRAINT

makakilos.” p. 734 intolerance as would and provide for ability to S ( Ms. MD is

be further relief of pain. participate in discharged

manifested by activities. already)

absence of pallor,

tolerable movement,

absence of body

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malaise.

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 CUES NURSING RATIONALE GOALS INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired skin Skin Short term: Independent: Short term:

integrity (primary line of After 1 day of Encourage early Promotes

“Ito medyo Related to defense against nursing ambulation. circulation and After 1 day of

makirot. mechanical bacterial infection) intervention, the reduces risk nursing

Hindi ko pa factors patient will associated with intervention, the

nga nakikta (surigical incised due to promote healing mobility. patient

tong sugat incision) surgical procedure as evidenced by Use appropriate Reduces promoted healing

ko kasi As manifested Maintaining dry padding device. pressure and as evidenced by

may gasa by: and intact enhances Maintained dry

pa. ” as “Ito medyo First line of defense incision site. circulation to and intact

verbalized makirot. Hindi is lost Long term: compromises incision site.

by the ko pa nga After 1 month of tissues.

patient nakikta tong Strict adherence to nursing Collaborative:

Objective: sugat ko kasi aseptic technique intervention, the Keep wound dry, Assists body’s

-Disruption may gasa pa. ” during surgery and patient will be clean and carefully natural process of GOAL MET

of the skin as verbalized in the days following able to : dress wound, repair

surface by the patient the procedure are Display that the support incision, Long term:

due to the -Disruption of necessary to wound will be prevent infection

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surgical the skin compensate for the totally healed and stimulate UNABLE TO

incision surface due to impaired defense. and has no circulation to RENDER DUE
CUES NURSING RATIONALE GOALS NURSING RATIONALE EVALUATION

INTERVENTION
DIAGNOSIS
SUBJECTIVE Disturbed Hospitalization SHORT INDEPENDENT SHORT TERM

: Patient Sleeping Pattern can usually TERM Discuss and explore with Identifying GOAL:

verbalized : “ related to disrupt sleep. GOAL : the client’s relatives the possible causes

Nako unfamiliar This maybe After 30 possible causes that helps the nurse After 30

kailangan ko surroundings due to several minutes of contribute to discomfort and client plan minutes of

nang umuwi, and medical factors such nursing in surrounding appropriate nursing

tumataas management as loss of intervention, environment. interventions to interventions

lang ang bili practices. familiar the patient promote sleep the patient had

ko dito, Hindi As manifested by surroundings, will be able to Render health teachings been able to

tuloy ako patient fear of the have a restful on promoting restful have restful

makatulog ng verbalized : unknown, sleep. sleep to the relatives sleep

maigi, saka “Nako kailangan disruption of such as:

nagaalala ko ng umuwi, sleep because LONG TERM a. Encourage the It promotes GOAL MET
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nadin ako sa tumataas lang of procedures GOAL : patient or her relaxation of her

anak ko.” ang bili ko dito, or treatment, After 2 days relatives to have body as well as LONG TERM

OBJECTIVE : hindi tuloy ako noise level of of nursing comforting hygienic the mind GOAL:

-Yawning makatulog ng privacy. intervention, rituals such as UNABLE TO

-Presence maiagi, saka Hospitalization the patient washing or cleaning RENDER DUE

of dark nagaalala nadin is disruptive of will be able to her body before TO TIME

circles ako sa anak ko.” normal sleep achieve going to sleep. CONSTRAINT

around because of the improvement b. Encourage patient to Because stress, S (Ms. MD is

-yawning
the eyes. change in the of sleep calm the mind by anxiety, and discharged
-presence of
- environment pattern as replacing negative worry can lead to already)
dark circles
Irritatable and hospital evidenced by thoughts with positive an active mind at
around the eyes
protocol. patient’s affirmations or having bedtime. It is
- irritable
Reference : verbalization soft music to play. essential to calm UNABLE TO

Nursing of the mind to RENDER DUE

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 fundamentals improvement facilitate quality TO TIME

( caring and in sleeping sleep. CONSTRAINT

clinical pattern c. Teach the patient to To have restful S (Ms. MD is

decision have a quiet environment and discharged

making ), environment in facilitate sleeping already)

2004 Rick preparation for sleep.

Daniels; pp.

1315-1316

ASSESSMENT NURSING RATIONALE GOALS INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Self Care deficit Decrease SHORT TERM: INDEPENDENT: SHORT TERM:

““Medyo (self-toileting and muscle tone After 1 day of After 1 day of

nanghihina pa grooming) is the result nursing -Encourage To decrease nursing

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ako, hindi pa Related to pain of the intervention the independence but frustrations in intervention the

ako and discomfort decrease in patient will be intervene when performing patient was able

masyadong the oxygen ale to perform patient can not activities to perform self

makakilos. As maniested by level of the self care perform. care activities

Katulad nito Subjective: brain which activities within within the level of

hirap ako ““Medyo there is the the level of its -Provide safety To avoid injury its own ability and

pumunta sa nanghihina pa motor own ability and precautions identified personal

CR mag-isa ako, hindi pa ako function to identify or community

tsaka mag-palit masyadong control the personal or resources that

ng damit. makakilos. movement of community -Provide It may enhance can provide

Lagkit na lagkit Katulad nito hirap the body, is resources that appropriate self care abilities assistance. “Ito

na nga ako ako pumunta sa the result of can provide assistive devices padischarge na

eh.”as CR mag-isa self care assistance. ako, kaya ko na

verbalized by tsaka mag-palit deficit -Use consistence This helps kumilos mag-isa.”

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the patient ng damit. Lagkit because in routines with patient to GOAL MET

na lagkit na nga there is the her self care organize and

Objective: ako eh.”as decrease in activities carry out self LONG TERM:

-Inability to rise verbalized by the muscle tone care skills. UNABLE TO

from the toilet patient. RENDER DUE

or commode Objective: TO TIME

-inability to get -Inability to rise CONSTRAINTS

toilet or from the toilet or Reference: (Ms. MD is

commode commode Nursing care discharged

-impaired -inability to get plan by Meg already)

ability to obtain toilet or Gulanick

or replace commode pg.53

articles of -impaired ability

clothing put on to obtain or

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or take off replace articles of

necessary clothing put on or

items on lower take off

extremities. necessary items

on lower

extremities.

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