Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Anxiety related to At the end of 15 1. Establish rapport. 1. To gain trust and After 15 minutes of nursing
upcoming surgical minutes of nursing cooperation. intervention, the patient was
“Kinakabahan ang operation. intervention, the patient able to reduce the feeling of
asawa ko sa operasyon will be able to reduce 2. Assess patient’s level 2. Different levels of anxiety as evidence by
nya” as verbalized by the feeling of anxiety of anxiety. anxiety will affect adherence to instructions
the patient’s wife as evidence by the coping given
adherence to mechanism.
instructions given
Objective: 3. Monitor vital signs. 3. To identify physical
responses
 Poor eye contact associated with
both medical and
 Paleness emotional
conditions.
 Deep breathing 4. Provide presence, 4. Being supportive
touch or and approachable
 Cold clammy verbalization to encourages
skin encourage verbalization
expressions or
 Vital signs as clarifications of
follows: needs and concerns
T- 36.8˚C
P-87 bpm 5. Provide accurate, 5. To help the patient
R-20 cpm concrete information identify what is
BP- about what procedure reality-based,
110/70mmHg he will undergo. provide assurance
and alleviate
patient’s anxiety as
well as provide
information.
6. Provide comfort 6. To soothe fears and
measures like provide assurance.
therapeutic touch,
quiet and calm
environment.

7. Tell patient 7. Involving patient in

anticipating local or the plan of care
spinal anesthesia that provides sense of
drowsiness and sleep control and helps
occurs that more decrease anxiety.
sedation may be
requested and will be
given if needed and
that surgical drapes
will block view of
the operative field.
 Assessment Diagnosis Planning  Intervention Rationale Evaluation

Subjective Data: Risk for infection After 2 hour of nursing 1. Monitor vital signs. 1. Vital signs are After 2 hour of nursing
related to post-op interventions the Assess signs & important baseline interventions, the patient
surgical incision patient will be able to; symptoms of data because it was able to;
secondary to surgery  maintain the infection especially proves possible  maintain the
integrity of temperature. infection. Fever integrity of surgical
surgical site to may indicate site to lessen the risk
lessen the risk 2. Note risk factors infection. of infection
of infection for occurrence of
infection in the 2. To help the patient
Objective Data: incision. identify the present
 Post op patient risk factors that
 Clean and intact 3. Observe for may add up to the
facial dressing localized size of infection.
 Vital signs as infection at
follow: insertion sites of 3. To evaluate the
T –36.8˚C surgical incision. character, presence
P – 87bpm and condition of
R –20 cpm 4. Make health possible infection.
BP – teachings
110/70mmHg especially in 4. To help the patient
identification of modify/change/avoi
environmental d some of the
factors that could environmental
add up on factors present
infection. which could reduce
the incidence of
5. Emphasize the infection.
importance of
handwashing 5. It serves as a first
 technique. line of defense
against infection.

6. Instruct the proper 6. To reduce the risk

hand washing of infection.
especially before
and after toileting,
meals and
administering self-
care.

7. Encourage to 7. To maintain fluid

increase fluid and electrolyte
intake. balance in the body.

8. Instruct the 8. Wound healing

importance of well- requires protein and
balanced diet high calories for
in protein calories. building new cells.
The immune
system depends on
those to produce
antibodies.

9. Encourage 9. To help regain

adequate rest strength.
periods.
10. Discuss the 10. To impart to the
following signs of patient when the
infection; redness, incision become
swelling, increased infected and when
pain or purulent to sought medical
drainage on the site care.
and fever.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for aspiration At the end of 1 hour 1. Noted client level 1. As impairments in After 1 hour operation client
related reduced level operation client will be of consciousness, these areas increase was able to:
of consciousness able to: awareness of clients risk of  experienced no
secondary to surroundings, and aspiration aspiration as
anesthesia  experience no cognitive function evidenced by
aspiration as noiseless
evidenced by 2. Maintained 2. A patient with respirations, clear
noiseless operational suction aspiration needs breath, sounds, clear,
respirations, equipment at immediate odourless secretion
Objectives: clear breath, bedside suctioning and will
 under general sounds, clear, need further
anesthesia odorless 3. Identify at-risk lifesaving
 decreased secretion client according to interventions such
respiratory condition as listed as intubation
function in risk factors 3. To determine when
 decreased level observation and or/
of 4. Assess the client’s intervention may be
consciousness ability to swallow required
 In supine and strength of
position gag/cough reflex 4. Helps to determine
 age (53) presence/
effectiveness of
protective
5. Positioned the mechanisms
patient with a
decreased level of 5. To decrease the risk
consciousness on of aspiration by
their side promoting the
drainage of
secretions out of the
mouth instead of
down the pharynx,
where they could be
aspirated.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain related to At the end of 2 hour 1. Note patient’s age, 1. Approach to At the end of 1 hour nursing
disruption of skin nursing interventions, weight, coexisting postoperative pain interventions, the patient
“Masakit kapag and tissue integrity the patient will be able medical or management is was able to:
nagsasalita na ako at secondary to surgical to: psychological based on multiple 2. Appear relaxed, able
kapag nagagalaw” as incision 1. Appear relaxed, conditions, variable factors to rest/sleep. No
verbalized able to idiosyncratic complaints of severe
rest/sleep sensitivity to 2. Presence pain.
without analgesics, and of narcotics and
complaints of intraoperative droperidol in
severe pain course systempotentiates
narcotic analgesia,
2. Review whereas patients
Objectives: Long term goal: intraoperative or anesthetized with
recovery room Fluothane
 pain scale of 8/10 At the end of 24 hour
record for type of and Ethrane have
 grimace of nursing intervention
anesthesia and no residual
 guarding behaviour the patient will reports
medications analgesic effects. In
 post surgical pain at tolerable level
previously addition,
incision administered intraoperative local/
 Vital signs regional blocks
taken: have varying
T: 36.8° duration, e.g., 1–2
P:87 bpm hr for regionals or
R:21 up to 2–6 hr for
BP:110/70 locals.
mmHg
3. Evaluate pain 3. Provides
regularly (every 2 information about
hour noting need for or
characteristics, effectiveness of
location, and interventions
 intensity (0-10).
Emphasize
patient’s
responsibility for 4. Concern about the
reporting pain / unknown and
relief pain preapare.
completely. Inadequate
preparation can
4. Note presence of heighten patient’s
anxiety or fear, and perception of pain
relate with nature
of and preparation 5. Discomfort can be
for procedure caused or
aggravated by
5. Assess causes of presence of non-
possible discomfort patent indwelling
other than catheters, NG tube,
operative procedure parenteral lines
(bladder pain,
gastric fluid and gas
accumulation, and
infiltration of IV
fluids or
6. Encourage use of medications).
relaxation
techniques: deep- 6. Relieves muscle
breathing exercises, and emotional
guided imagery, tension; enhances
visualization, sense of control and
music may improve
coping abilities
7. Assess vital signs, 7. Changes in these
noting vital signs often
tachycardia, hypert indicate acute pain
ension, and and discomfort.
increased Note: Some
respiration, even if patients may have a
patient denies pain slightly lowered
BP, which returns
to normal range
after pain relief is
achieved
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective : Risk for Imbalanced At the end of 1 hour 1. Note preoperative 1. Served as baseline After 1 hour of nursing
Body Temperature nursing interventions, temperature for monitoring interventions, the patient
Related to anesthetic the patient will be able 2. Assess intraoperative was able to;
agents secondary to to; environmental temperature  Maintain body
surgical operation  Maintain body temperature and 2. May assist in temperature within
temperature modify as needed: maintaining or normal range
within normal providing warming stabilizing patient’s -T: 36.8°C
range (36.5- and cooling temperature.
Objective: 37.5 ℃) blankets, increasing
 Under general room temperature
anesthesia 3. Heat losses will
 Vital signs 3. Cover skin areas occur as skin (legs,
taken: outside of operative arms, head) is
T:36.8°C field exposed to cool
P:87 bpm 4. Provide cooling environment
R: 20 measures for 4. Cool irrigations and
BP:110/70 patient with exposure of skin
mmHg preoperative surfaces to air may
temperature be required to
elevations. decrease
temperature.
5. Note rapid
temperature 5. Malignant
elevation or hyperthermia must
persistent high be recognized and
fever and treat treated prompty to
promptly per avoid serious
protocol. complications and
or/ death
6. Increase ambient
room temperature 6. Helps limit patient
 (e.g., to 78°F or heat loss when
80°F) at conclusion drapes are removed
of procedure. and patient is
prepared for
transfer.

7. Apply warming 7. Inhalation

blankets at anesthetic depress
emergence from the hypothalamus,
anesthesia. resulting in poor
body temperature
8. Monitor regulation
temperature
throughout 8. Continuous warm
intraoperative or cool humidified
phase inhalation
anesthetics are used
to maintain
humidity and
temperature balance
within the
tracheobronchial
tree. Temperature
elevation and fever
may indicate
adverse response to
anesthesia. Note:
Use
of atropine or scopo
lamine may further
increase
temperature.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Disturbed thought After 1 hour of nursing 1. Reorient patient 1. As patient regains After 1 hour of nursing
process related to intervention the patient continuously when consciousness, intervention the patient was
reduced level of will be able to: emerging from support and able to:
consciousness  regain usual anesthesia; confirm assurance will help  regain usual level of
secondary to level of that surgery is alleviate anxiety consciousness. The
Objectives: anesthesia consciousness completed 2. The nurse cannot patient is oriented to
 post op patient 2. Speak in normal, tell when patient is place and time
 disoriented clear voice without aware, but it is
shouting, being thought that the
aware of what you sense of hearing
are saying. returns before
Minimize discussion patient appears
of negatives within fully awake, so it is
patient’s hearing. important not to
Explain procedures, say things that may
even if patient does be misinterpreted.
not seem aware Providing
information helps
3. Evaluate sensation patient preserve
and/or movement of dignity and prepare
extremities and for activity
trunk as appropriate
3. Return of function
4. Use bedrail padding, following local or
restraints as spinal nerve blocks
necessary depends on type or
amount of agent
5. Observe for used and duration
hallucinations, of procedure
delusions,
depression, or an 4. Provides for patient
 excited state safety during
emergence state.
6. Evaluate need for Prevents injury to
extended stay in head and
postoperative extremities if
recovery area or patient becomes
need for additional combative while
nursing care before disoriented
discharge as
appropriate 5. May develop
following trauma
and indicate
delirium, or may
reflect
“sundowner’s
syndrome” in
elderly patient. In
patient who has
used alcohol to
excess, may
suggest impending
delirium tremens

6. Disorientation may
persist, and SO
may not be able to
protect the patient
at home