CUES DATA: NURSING INFERENCE GOAL INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Subjective: Impaired physical The presence of SHORT TERM: INDEPENDENT: *to maintain SHORT TERM:
mobility related to surgical incision *support affected position of
“ hirap gumalaw pain/discomfort. site which causes After 1 day of nursing body parts using function. After 1 day of nursing
sakit pa nitong sugat pain to the client intervention the patient pillows and so on. intervention the short
ko eh” as patient causing her to limit will be able to increase * promotes well term goal is fully met as
verbalized. her movements. her mobility as * encouraged being and manifested by:
manifested by: adequate intake of maximizes energy
Objective: - Decreased the fluids and nutritious production. *pain scale of 4 from 8
pain to at least 4 foods.
- Pain scale of from 8 in pain * limits fatigue, *patient shows increase in
8 out of 10. scale. * identify energy maximizing her movement.
- Shows increased conserving participation.
- Post op. in her movement. techniques for ADLs *func. Level of 2 – requires
Surgical - Func. Level of 2- help from another person
incision site requires help from DEPENDENT for assistance.
another person for
- Limited assistance. *administer *to permit maximal LONG TERM:
movement medications prior to effort/involvement
LONG TERM: activity as needed for in activity. After 4 days of nursing
- Functional pain relief. intervention the long term
level: After 4 days of nursing goal is fully met as
intervention the patient COLLABORATIVE: manifested by:
3- Requires will not experienced
help from difficulty in her mobility *consult with *to develop *pain scale of 0.
another as manifested by: physical/occupational individual
person and therapist, as exercise/mobility *func. Level of 0 –
equipment *pain scale of 0 indicated. program and completely independent
device. *func. Level of 0- identify
completely independent. appropriate
mobility devices.
 NURSING
CUES DATA: DIAGNOSIS INFERENCE GOAL INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective Pain SHORT TERM: *observe respiratory rate/depth. *shallow breathing, SHORT TERM:
breathing experiencing by splinting with
“medyo pattern may be the patient due After 1 day of nursing respiration, holding After 1 day of
nahihirapan nga related to pain to surgical intervention the patient breath may result in nursing intervention
ako huminga kc on surgical incision made would be able to hypoventilation/ the short term goal
masakit pa to.” incision site. that would made experienced decrease atelectasis. is fully met as
- As verbalized interrupt to her difficulty in her breathing manifested by:
by the breathing pattern as manifested by: * assess for concomitant *may restrict limit
patient. pattern. pain/discomfort respiratory effort. *RR of the patient
- RR of at least 23 decreased to at least
Objective: breaths/min. *note emotional responses *anxiety may be 23 breaths/min.
- Patient verbalized causing exacerbating
- RR – 26 fewer complaints acute/ chronic *fewer complaints
breaths/min regarding her hyperventilation. noted.
breathing pattern.
- Nasal flaring *elevate head of bed. *facilitates lung LONGTERM
LONG TERM: expansion.
After 5 days of
After 5 days of nursing *assist with respiratory treatment *maximizes expansion nursing intervention
intervention the patient e.g. incentive spirometer of lungs to prevent the long term goal is
would be able to have an atelectasis. fully met as
absence of difficulty in manifested by:
her breathing pattern as *administer pain medication as
manifested by: ordered. *absence of nasal
flaring.
*absence of nasal flaring *no complaints
*RR bet. 12-20 noted.
breaths/min. *RR between 12-20
*verbalized improve breaths/min.
breathing pattern with no
complaints noted.
 NURSING
CUES DATA: DIAGNOSIS INFERENCE GOAL INTERVENTIONS RATIONALE EVALUATION

Subjective: Acute pain Peripheral SHORT TERM: Eliminate additional stressors or Patient may SHORT TERM:
related to nervous system sources of discomfort whenever experience an
- “masakit pa postoperative includes primary After 8 hours of nursing possible exaggeration in pain After 8 hours of
talaga ung incision. sensory neurons intervention the patient or a decreased ability nursing intervention
sugat ko.” specialized to experienced decreased in to tolerate painful the short term goal
As patient detect tissue pain as manifested by: stimuli if is fully met as
verbalized. damage and to environmental, manifested by:
evoke the *pain scale of 4 from 8 intrapersonal, or
Objective: sensation of *decreased facial intrapsychic factors *pain scale of 4 from
heat, touch, grimace are further stressing 8
- Guarding pain and *slight guarding behavior them *decreased facial
behavior pressue. grimace
- Pain scale of LONG TERM: Diverticulate activities These heightn one’s *slight guarding
8 out of 10. concentration upon behavior
- Post op After 3 days of nursing nonpainful stimuli to
surgical intervention the patient decrease one’s LONGTERM
incision site would be able to awareness and
- Facial experienced absence of experience of pain. After 3 days of
grimace pain as manifested by: nursing intervention
Reference: Provide rest periods to facilitate Pain may result to the long term goal is
Fundamentals of *pain scale of 0 comfort, sleep, and relaxation fatigue, which may fully met as
nursing 7th *no facial grimace result in exaggerated manifested by:
edition by *absence of guarding pain and exhaustion.
Barbara Kozier , behavior. *pain scale of 0
Chapter 44 Relaxation exercise, biofeedback, to reduce tension, *no facial grimace
pg.1135 breathing exercise subsequently *absence of guarding
reducing pain. behavior

Administer analgesic as ordered To reduce the pain