Republic of the Philippines

PALAWAN POLYTECHNIC COLLEGE INC

Manalo Extension, Puerto Princesa City
Bachelor of Science in Nursing

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain r/t post-op on Independent Short Term Goal:

Short Term Goal:
left extremity of pain from
“Ang masakit ang sugat ko lalo the patient as evidenced by 1. Assess for intensity of pain 1. To determine the efficacy of After 1 hour of nursing intervention
na pag gumagalaw ako.”as After 1 hour of nursing scale 0-1 interventions aimed at reducing the Goal was met, the patients was
reports of pain from the
verbalized by the pt. patient, rating pain scale intervention the patient will be pain. able to demonstrate and use non
8/10. pharmacological ways to relieve
-Pain scale of 8/10 able to demonstrate non
2. Promote general comfort pain such as deep breathing
2. Investigate changes in pain
Definition: NANDA based: pharmacological ways to relieve measures. exercises and distraction.
Objective: characteristics, numbness,
unpleasant sensory and pain such as deep breathing and tingling. After administered the drug the pt.
emotional experience
 Pain scale of 8/10 associated with the actual exercises and distractions. pain scale is 3/10.
3. Instruct the patient to use 3. To relieve pain by activating
 Alteration inability to or potential tissue damage,
deep breathing exercises. parasympathetic response
or described in terms of
continue previous which relaxes the body.
such damage sudden, or
activities slow onset of any intensity
 Seeking out comfort from mild to severe an
anticipated or predictable
 Restlessness
end, and a duration of less
 Impaired physical than 6 months. 4. Used non-pharmacological 4. To relieve pain.
intervention such as
mobility
distraction (watching
 Disturbed sleep pattern television and listening to
Etiology: Post-op on left leg music)

Background of theory:
Kolcaba’s comfort theory
explains comfort as a
fundamental need of all
human beings for relief,
ease, or transcendence
arising from health care Dependent:
situations that stressful.
1. Administer drug
ketorolac to relief pain
after the surgery.
 Republic of the Philippines
PALAWAN POLYTECHNIC COLLEGE INC
Manalo Extension, Puerto Princesa City
Bachelor of Science in Nursing

ASSESSMENT NSG. DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for Infection r/t to post Short term goal: Independent: Short term goal: Care goal achieved. After 1
op incision hour of nursing intervention the patient:
“Hindi po ba yan maimpeksyon After 1 hour of nursing 1. Assess and monitor any 1. To manage and prevent
intervention, the patient will be signs or symptoms of the transmission of
yong sugat sa tahi ko”
able to: infection such as redness, infections.
swelling, increased pain, or Identified the intervention to prevention to
As verbalized by the pt. Definition:
 Identify interventions purulent discharge from prevent or reduce risk of infection.
to prevent or reduce incision.
Objective: Postoperative infections may
risk of infection. 2. to protect the skin integrity
be cause severe problems,  Demonstrate
 With post-surgical 2. Apply the procedure such of the skin, care for lesions
including failure of the techniques and life as wound dressing to such as handwashing
incision at left lower surgical procedure, other style changes to prevent the infection and before touching the client,
extremity surgical complications, promote a safe other microorganisms. cleaning, or aseptic
sepsis, organ failure, and environment. procedure, after touching
even death. client and client’s
surroundings.

3. To know ways on how to

reduce or eliminate germs
reduces the like hood of
transmission.
 Republic of the Philippines
PALAWAN POLYTECHNIC COLLEGE INC
Manalo Extension, Puerto Princesa City
Bachelor of Science in Nursing

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation

Independent
Subjective: Risk for Fall Short term goal: Short Term Goal:
 Identify needs or deficits  Concerning clearing of
“hindi kaya ako mahulog After 1 hour of nursing provides opportunities. hazards obtaining safety After 1 hour of nursing intervention the Goal was
habang nakahiga ako. Iniisip ko intervention, the patient will be equipment met, the patients was able to:
pagkatapos ng operasyon ko Definition: susceptible to able to:
mahirap na ako makalakad”as increased [risk for] falling,  Verbalized understanding of individual
 To manage condition that
verbalized by the pt. which may cause physical  Demonstrate risk factors that contribute possibility of
 Recommend or implement contribute to falling and to
harm and compromise health behaviors and falls.
needed of safety devices promote safe
Objective: lifestyle changes to  The pt. be free of injury
such as; wheelchair and environment
reduce risk factors
 Advance age side rails to keep the pt.
and protect self from
safety and secured for fall.
 Body weakness injury
 Difficulty walking  Modify environment
 High risk for falling as indicated to
 Impaired mobility enhance safety