DATA PATHOPHYSIOLOGY GOALS NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: (Explanationof the Nursing STG: (After _____ hour/s (Diagnostics, Therapeutics, Educative) (After____ hour/s of nursing
Problem; Diagram) the patient will be able to intervention the ____ goals
Objective (PE, Labs) >Established rapport >To build trust and comfort to the patient.
___ as evidence by) were ___________ met as
>Afebrile > Functional endoscopic > After 3 hours of nursing evidence by)
sinus surgery (FESS) is > Monitor the client’s vital signs, >Fever indicates that the body’s defenses are
>Conversant and coherent procedure that involves intervention Patient will especially the temperature fighting off harmful microorganisms. A temperature > After 3 hours of nursing
of more than 100.4℉ (38℃) after the first 24 hours
Initial Vital signs as follows: enlarging the natural be able to understand the of birth and two consecutive 24-hour periods may intervention Patient was able
connections between indicate an infectious process. The nurse should
BP:120/80mmHg sinuses and nose in a importance of preventing to understand the importance
also look for other signs of infection if the client’s
T:36.7C minimally invasive manner infection to nasall area as temperature is elevated, regardless of the time since of preventing infection to
using small telescopes. delivery.
SpO2:98% evidence by patient perineal area as evidence by
> Educate the client and family members
HR:78bpm verbalizing ways to about proper hand-washing and self-care patient verbalizing the proper
They inject a numbing >Proper hand hygiene is the primary method to
RR: 16cpm solution into your nose. prevent the spread of techniques. Review appropriate handling prevent the spread of infectious organisms. ways to prevent infection in
and disposal of contaminated materials
infection and taking the nasal area and taking the
Using the endoscope, they
antibiotics as prescribe. > Educate the client on how to perform
gently enter your nose. antibiotics as prescribe.
proper oral hygiene > To prevent infection, odor and irritation in nasal
RN Diagnosis: (PE; PES format)
They insert surgical tools area.
Risk for infection related to LTG: (After > Educate the client on identifying signs
alongside the endoscope
inadequate primary of infection and when to notify the > Some clients may develop an infection days after
to use the endoscope to ____hours/days the
defense (skin): perineal tear healthcare provider. discharge. They should be taught how to take their > After 7 hours of nursing
remove bone, diseased temperature and when to notify their healthcare
and stitches patient will be able to ___ intervention, the client was
tissue or polyps that may provider.
Risk for infection related to > Use aseptic technique for all wound
be blocking your sinuses. as evidence by) care and invasive procedures. able to remain afebrile
inadequate primary defense: > Contamination by environmental or personnel
>After 7 hours of nursing contact renders the sterile field unsterile, thereby throughout hospital stay as
minimal invasive procedure Minimal invasive procedure intervention, the client will increasing the risk of infection.
>Encourage the client to increase intake evidence by temperature not
(FESS) of high protein, iron, and vitamin C-rich
Risk for infection be able to remain > Foods high in iron, such as meats, enriched going above 37.4C
Reference (All): foods. cereals and bread, and dark, green, leafy vegetables
afebrile throughout
help correct anemia. high in protein and vitamin c-
>NANDA
hospital stay as evidence rich foods are important for healing.
> Fundamentals of Nursing14th
edition,by Kozier and Erbs by temperature not going .
>Administer IV antibiotics as ordered.
above 37.4C
>A broad-spectrum antibiotic may be ordered until
the results from culture and sensitivity are available,
 at which time organism-specific antibiotics may be
started. If the client is continuing drug therapy at
home, stress that she must take the full course to
DATA PATHOPHYSIOLOGY GOALS NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: (Explanation of the Nursing Problem; STG: (After _____ hour/s (Diagnostics, Therapeutics, Educative) (After____ hour/s of nursing
Diagram)
the patient will be able to intervention the ____ goals
>The client verbalized “napulatan jay aggong ko
___ as evidence by) were ___________ met as
lalo na jay right side ken makaanges ak ditoy left
evidence by)
ngem batit lang” > Assessed general health condition > To established a baseline data
>Patient seen breathing through mouth
After 5 hours of nursing
After 5 hours of nursing
intervention, the client reported
intervention, the client will > Monitor V/S and vital sign > To established a baseline data
relieved of pain as evidence by
be able to understand in >Encourage verbal report s during and after > Pain is highly subjective and to identify the
Objective (PE, Labs) decreased in pain scale pain
nursing intervention effectiveness of the effectiveness of the
causative factors of his
V/S: intervention. scale of 6/10 to a manageable
>Assessed the clients history.
condition as evidenced by
>BP: 120/80 mmHG >The health history initially focuses on the client’s level 0/10
patient verbalizing risk
presenting problem and associated symptoms.
>HR: 87 BPM
factors and signs and >Determine the client’s and family members’
knowledge about risk factors for ineffective >To determine educational and support needs
>RR: 19/minute symptoms
airway clearance.
>TEMP: 37.2ºC Retained secretions
LTG: (After hours/days the >Review the client’s and family member’s >Understanding the disease process helps the client
>S02: 95%
patient will be able to ___ understanding of the disease process. and their family members comprehend the rationale
Clogged nose behind their prescribed treatments, medications, and
>Facial Grimace as evidence by)
therapies. Thus, they are more likely to adhere to
>Narrowed focus the treatment plan.
Seen breathing through mouth >Position the client upright if tolerated.
> Guarding behavior >Upright position limits abdominal contents from
Regularly check the client’s position to
After 8 hours of nursing pushing upward and inhibiting lung expansion. This
RN Diagnosis: (PE; PES formatute prevent sliding down in bed.
Ineffective airway clearance intervention, the client will position promotes better lung expansion and
Ineffective airway clearance related to retained >Encourage the client to increase fluid intake improved air exchange.
verbalize response to acute
secretion in nasal area as evidence by patient to three liters per day within the limits of >Fluids help minimize mucosal drying and maximize After 8 hours of nursing
seen breathing through mouth situation as evidenced by cardiac reserve and renal function. ciliary action to move secretions. intervention, the client
positive outlook to future
Reference (All): >Provide oral care every four hours. >To avoid odor and irrititaion in mouth verbalized sense of control of
>NANDA >To avoid feeling of anxiety and Recognize the response to acute situation as
>Consider verbalization of feelings.
DATA PATHOPHYSIOLOGY GOALS NURSING INTERVENTIONS reality of the situation RATIONALE evidenced by positive outlook to
EVALUATION
> Fundamentals of Nursing14th

Subjective: (Explanation of the Nursing Problem; STG: (After _____ hour/s the patient (Diagnostics, Therapeutics, Educative) (After ____ hour/s of nursing intervention
Diagram) will be able to ___ as evidence by) the ____ goals were ___________ met as
>The client verbalized “Masakit yung naopera,” evidence by)

>Pain scale of 6/10 as 0 is the lowest and 10 as > Assess the client pain scale and perception After 5 hours of nursing intervention, the
After 5 hours of nursing intervention, > To identify the onset and intensity of the pain client reported relieved of pain as evidence
the highest
Narrowed Focus the client will be able to report relieve by decreased in pain scale pain scale of
Objective (PE, Labs) of pain as evidence by decreased in > Monitor V/S and vital sign 6/10 to a manageable level 0/10
> To established a baseline data
pain scale pain scale of 6/10 to a
V/S: >BP: 130/80 mmHG
Guarding behaviour manageable level 0/10
>HR: 83 BPM >Reiterate the importance of hand hygiene
>To avoid infection and the spread of microorganism
>Encourage verbal report s during and after nursing
>RR: 19/minute Facial Grimace intervention > Pain is highly subjective and to identify the effectiveness of the
LTG: (After hours/days the patient will effectiveness of the intervention.
>TEMP: 37.2ºC
be able to ___ as evidence by)

>S02: 95% Verbalized felt pain in operative site

(nasal area)
>Facial Grimace
After 8 hours of nursing intervention,
>Narrowed focus > Administered the medication as prescribe by the Physician:
Pain scale of 6/10 the client will verbalize sense of control > To control bleeding
of response to acute situation as
> Guarding behavior >To decreased pain
evidenced by positive outlook to future.
RN Diagnosis: (PE; PES formatute Acute Pain

After 8 hours of nursing intervention, the

Acute Pain related to post-operative procedure as
>Advised patient not to eat spicy and hot foods client verbalized sense of control of
evidence by facial grimace and verbal report of felt > To avoid irritation and avoid increase of pain sensation
response to acute situation as evidenced by
pain in nasal area
positive outlook to future.
Reference (All): >Promoted non pharmacological pain management such as
quiet environment and change the position of the patient >To relieve pain and facilitate comfort and rest
>NANDA according to its preference.

> Fundamentals of Nursing14th

edition,by Kozier and Erbs >To provide comfort

>Advised breathing exercise

>To prevent infection, odor and irritation in nasal area.
>Advised patient to do proper oral hygiene
ENT WARD (June 15-17, 2023)

FDAR
NCP
DRUG STUDY
SUBMITTED BY: PADILLA, WENDEE A
SUBMITTED TO: MA’AM KAWI, SHELYN CLAIRE