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ASSESSMENT

DIAGNOSIS

PLANNING

NURSING INTERVENTIONS
INTERVENTIONS Change the position of the patient Provide comfort measures Assist patient in breathing techniques Provide quiet environment Relay on the patient report of pain Encourage divertional activities Monitor vital sign Administer analgesic as ordered by the AP RATIONALE Pain is sometimes due to the position of the patient To reduce the discomfort To assist in muscle and generalized relaxation For patient comfortability and lessen the discomfort. To reduce anxiety felt by the patient To divert the attention from pain to activities Usually altered in pain. To maintain acceptable level of pain.

EVALUATION

SUBJECTIVE CUES : Masakit ang tahi ko as verbalized by the patient. OBJECTIVE: Restlessness Excessive perspiration Facial grimace Increased respiration RR=26 bpm Pain scale = 7: pain scaling of 110 where 1 is the least painful and 10 is the most painful Impaired thought

Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.

After 4 hours of nursing intervention patients pain evidenced by pain scale =7 be reduced to 3.

After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.

ASSESSMENT
OBJECTIVE: Weak in appearance Pale looking v/s of: BP = 100/80, 110/70 PR = 90,75 RR =14,16 T = 36.3, 36.9

DIAGNOSIS
Fluid volume deficit related to the risk of post-operative hemorrhage.

PLANNING
After 8 hours of nursing intervention the patient will maintain fluid at a functional level.

NURSING INTERVENTIONS INTERVENTIONS


Change dressings frequently Provide frequent oral care Measure input and output Monitor v/s Administer IV fluids as indicated Give medications as ordered by the attending physician

EVALUATION
After 8 hours of nursing intervention, the patient was maintained fluid as manifested by good skin turgor

RATIONALE
To protect the skin and monitor losses To prevent injury from dryness To monitor fluids in the body To assess the patient and it serve as base line data helps maintain fluids in the body To reduce blood loss

ASSESMENT

DIAGNOSIS

PLANNING

NURSING INTERVENTIONS
INTERVENTIONS RATIONALE To reduce the fatigue Promotes well being and maximize energy production To exercise/mobiliz ation of body parts and develop muscle strength Enhances self concept and sense of independence Provide activities with adequate rest period. Encouraged adequate intake of fluids Advise to move hands and legs slowly Encourage participation in self care

EVALUATION

SUBJECTIVE: Hindi ako makagalaw ng ayos as verbalized by the patient. OBJECTIVE: Impaired ability to turn side to side. Cannot eat without support Slowed movement Irritable Limited ROM

Impaired mobility related to decreased muscle strength as manifested by limited ROM.

nursing intervention the patient will be able move safety and independently.

After 8 hours of nursing intervention, the patient was able to move safely and independently.

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