Pre-operative Phase

Cues and evidences Nursing diagnosis objectives interventions Rationale evaluation

Subjective: Body image disturbance During the preoperative
 Verbalized “Dili r/t negative perception of phase, the client will 1. Listen to client and - Establishes
Objectives
rapport
were fully
unta ko ganahan the present situation manifest an improved correct misconceptions and trust, allowing met as evidenced by:
ma operahan kay body image a/e by the: about the rehabilitation. expression of anxiety
magka-peklat ko.” and fears. This helps  Verbalization of “ I
 Acknowledgment of patient ventilate think makaya rajud
 Verbalized “Basin the change in body doubts and relieve ni nako. Na.a naman
dili na maganahan image. concerns. gyud ni, I’ll learn to
akong bana nako. live with it.”
Feel nako pangit  Participation in 2. Have client describe - Determines client’s
na kaayo ko.” decision making about self, noting what is views on self; develops  “im sure love ra
her care. positive and what is self awareness & gihapon ko sa akong
 Verbalized “Wa ko negative. Be aware of provides assurance bana bahalag unsay
katulog ug tarong  Communication of how client believes others that she can overcome mahitabo nako.”
gabii kay sige ko feelings about change to see self crisis.
ug huna-huna sa in body image.  Receives visitors
operation.” 3. Involve patient with - Determines clients
 Expression of positive discussions that will coping mechanisms  Interacts with others
 Verbalized “Wa feelings about self. provide further insights thus allowing for
koy gana mo- into patient’s coping reinforcement.
kaon.”  Recognition and patterns and self esteem  Chooses to decide
incorporation of body for herself
Objective: image change into
 Refused to see self-concept without 4. Arrange for client to -  Relaxed
A support groupand
visitors negating self esteem. interact with others who allows patient to share pleasant facial
 Becomes share the same mutual support and expression
depressed &  Talks with someone experience. caring with other who
anxious whenever who has experienced can fully understand.
her upcoming the same problem Being able to relate to
operation is other people will give a
mentioned.  Demonstration of the sense of belonging and
 Manifested lack of ability to practice two will help in accepting
appetite. new coping behaviors the circumstances
Consumed only
1/3 of her lunch. 5. Explain the importance - to promote maximal
 Minimal verbal and function of the function, and enables
interaction with procedure with regards to client to return to his
others the client’s health and previous lifestyle as
 Refuses to decide well-being. much as possible
for herself
6. Provide positive - To increase
reinforcement to patient’s
probability that a
efforts to adapt.
healthy adaptation will
continue.
7. Observe client’s
- Distortions in body
interaction with significant
Pre-operative Phase
Cues and evidences Nursing diagnosis objectives interventions Rationale evaluation
Subjective:
 Verbalized, “nahadlok Anxiety r/t impending During the preoperative 1. Monitor vital -Establish baseline data Objectives were
jud ko. Mao ni akong operation phase, the client will manifest signs - an increase in RR, fully met as
first operation. What if a decreased level of anxiety PR and BP may evidenced by:
mamatay ko?” a/e by: indicate that the
patient is anxious - v/s w/in normal
 Verbalized, “Ana man  Openly discussing range:
gud akong amiga na feelings and  this may interfere with T: 37 C
lisod na magpa-opera expressing reduced 2. Be aware of ability to deal with the P: 80 bpm
kay daghang anxiety before surgery defense mechanisms problem R: 18 cpm
complications.” being used BP: 120/80 mmHg
 Appearing relaxed and  establishes rapport and
 Verbalized, “sige ko reporting that anxiety 3. Establish open, trust, allowing expression of  Verbalized of:
ug mata-mata. Wa jud is reduced to a honest communication anxiety and fears “Murag ready
ko katulog ug tarong manageable level nako sa akong
gabii.”  will develop awareness surgery.
 Identify healthy ways 4. allow free towards problem Nadawat naman
Objective: to deal with and expression of fears and sa nako na
express anxiety negative feelings  most clients feel less kinahanglan jud
 T: 37 C anxious when they know ni siya. »
 P: 108 bpm  Minimal perspiration what to expect on
 R: 24 cpm 5. reinforce awakening from surgery  Verbalized,
 BP: 130/80 mmHg  Absence of information concerning - to correct any « naa naman
restlessness and dry gastrectomy misconceptions gud ko’y idea
 Persipiration noted mucosa unsay mahitabo
 involving the family will mao dili na
 Restlessness noted  Return of usual 6. Determine the provide adequate support kaayo ko
sleeping pattern clients level of knowledge system to the client and will anxious.”
 Poor eye contact aid in post operative
noted  Use of support 7. ask significant recovery.  Appeared
systems to cope with others how they feel relaxed and
 Dry mouth noted anxiety about the gastrectomy well-rested
and how they perceive  coping mechanisms
 Slept for only 4 hours  Involvement of patient the client to be provide a healthy avenue for  Interacted
that night (normal in decisions about care responding the displacement of anxiety pleasantly with
hours of sleep is 8-10 bantays
hours)  Performance of stress- 8. reinforce usual
 Appeared reduction techniques coping mechanisms if  Minimal
apprehensive and to decrease anxiety these are effective, aid in perspiration
distressed the discovery of new - thus reassuring the noted
coping mechanisms if old patient that
ones are ineffective  Discovered that
listening to
9. thoroughly - increases self-help classical music
attend to the patients and foster was relaxing
physical needs independence
- distracting the client  Slept peacefully
Pre-operative Phase
Cues and evidences Nursing diagnosis objectives interventions Rationale evaluation
Subjective:
knowledge deficit r/t During the preoperative - Establish an - a patient who is Objectives were fully
 Verbalized, “ wala expectations after surgery phase, the client will environment of mutual comfortable and has trust met as evidenced by:
koy idea kung display adequate trust and respect towards the health
unsay buhaton knowledge concerning 1. Ascertain level of personnel will be more  Verbalized “ dili ra
during ug after sa postoperative knowledge, including likely to be more diay na sakit sa
akong operation” expectations a/e by: anticipatory needs. cooperative operation na jud
kay naa man diay
 Verbalized, “basin  Active anesthesia..”
dili na ko maka- participation in 2. Determine client’s  determines what the
kaon ug tarong health teachings ability to learn client already knows and  Able to give
kay kwaon na gives nurse an idea of pertinent
akong stomach.”  Exhibition of what must be taught information
increased interest concerning
 Verbalized, for own learning 3. Determine any  determines what surgery
“kailangan pa ba obstacles to learning (e.g. teaching strategy must be
jud ni nga  Expression of language barriers) used in order to enhance  Strict adherence
surgery?” understanding of teaching-learning to pre-op
the usual effectiveness instructions noted
Objective: postoperative
regimens  will interfere with
 Was about to learning and should be
drink water after dealt with first before
instruction of NPO  Verbalization of learning can take place.
was given. correct
 Highschool information 4. Conduct health  promotes patient
graduate regarding surgery teachings on: education
 exercising legs and
 Patient states arms several times a
intention to make day
needed changes in  strictly limiting
lifestyle weight bearing until
instructed otherwise

5. Include family
members in health
teaching
6. have patient
incorporate learned skills
into daily routine
 involving family
reinforces client’s support
system
- this allows the client to
practice learned skills and
receive feedback
Intraoperative Phase
Cues and evidences Nursing diagnosis Objectives Interventions Rationale Evaluation
Objective:
High risk for secondary During the intraoperative 1. Monitor vital signs and  for baseline data and to Objectives were
 Invasive infection r/t break in skin phase, the client will not laboratory exams check for any abnormal fully met as
procedure integrity secondary to manifest signs and findings evidenced by:
surgical procedure symptoms of secondary
 Gastrectomy done infection a/e by:  Vital signs
2. Adhere to facility  to prevent contamination, remained within
 Vital signs within  Vital signs remain infection control, and spread of microorganisms normal range
prescribed limits within prescribed sterilization and aseptic
T= 37.1 C limits ( T= 36.5 policies and procedures  Incision site is
HR = 71 bpm, strong -37.5 C, HR= 60-  to ensure that all items to free of purulent
and regular 100 bpm, RR = 3. check the package be used are sterile discharge
RR= 17 cpm, regular, 12-20 cpm) integrity, chemical
without use of indicator, and expiration  Absence of
accessory muscles  Incision site is free date on all sterile redness and
BP= 120/80 mmHg of purulent materials  To cleanse and prepare the inflammation of
drainage site for gastrectomy incision site
 Lab and diagnostic 4. Verify that initial and
test results within  Absence of final skin preparation has  Absence of
prescribed limits redness and been done  to ensure smooth and evisceration and
inflammation accurate performance of the dehiscence
 WBC= 5.5 5. Prepare operative site operation
T/cumm  Absence of according to specific
evisceration and procedures
 Adequate skin dehisence  prevents the spread of
preparation done infection
6. Provide sterile drapes
and dressings as  assures the maintenance of
necessary sterility all through out the
procedure
7. Monitor for any breaks
in the sterile technique - decrease the incidence
of wound infection

8. administer antibiotics
as ordered.
Intraoperative Phase

Cues and evidences Nursing diagnosis objectives interventions Rationale evaluation

Objective:
 For below the High risk for fluid volume During the intraoperative 1. Assist anesthesist in  for baseline data and Objectives were fully
gastrectomy imbalance r/t excessive phase, the client will monitoring vital signs to check for any abnormal met as evidenced by:
 Diabetes mellitus blood loss demonstrate adequate findings
noted fluid volume imbalance  Vital signs remained
 Vital signs stable a/e by: within normal range
T= 37.1 C  Stable vital signs 2. Auscultate BP, calculate  PP widens before
HR = 71 bpm, strong T= 36.5 -37.5 C, pulse pressure, systolic BP drops in  Laboratory tests
and regular HR= 60- 100 bpm, response to fluid loss stable
RR= 17 cpm, regular, RR = 12-20 cpm
without use of accessory 3. Monitor any underlying  Provides information  Urine output of 50
muscles.  Urine output of disease condition, client’s regarding ability to ml/ hr of yellow,
more than 30 ml/hr age, current level of tolerate fluctuations in clear, urine
 Laboratory and hydration, and mentation fluid level and risk for
Diagnostic tests stable  no dryness of lips, failing to respond to  No dryness of lips,
Hgb = 13 gm% tongue and mucous problem tongue and mucous
Hct = 39 % membranes membranes noted
4. Measure and record I  helps determine client’s
 Presence of D5LR 1L & O. hydration status  No edema noted
@ left metacarpal  no presence of
vein @ 600 cc level edema 4. Assess for clinical signs  indicates client’s
running well @ 30 of dehydration hydration status
gtts/min & PNSS 1L @ (hypotension, dry skin/
right metacarpal vein mucous membranes,
with 900 cc level delayed capillary refill
running well at 10
gtts/min 5. Monitor IV fluids  to promote fluid
management
 Presence of FBC noted
 NPO status 6. Confirm that  replenishes lost blood.
emergency blood packs Promotes hemodynamic
are available and perform stability
blood transfusion as
necessary
Intraoperative Phase
Cues and evidences Nursing diagnosis objectives interventions Rationale evaluation

 For gastrectomy Risk for injury r/t During the intraoperative 1. Secure in proper  ensures the safety of Objectives were fully
perioperative positioning phase, the client will be position with the use of the patient met as evidenced by:
 Administration of free from injury a/e by: straps, rails and other
regional anesthesia protective equipment  skin integrity,
 Immobility  Skin integrity is aside from the
 Mechanical factors intact 2. provide pads, and  client may have to operative site is
including friction pillows at areas with bony remain in the same intact
and pressure  Maintains proper prominences position for a long period
position throughout of time, pillows cushion  was able to
the procedure the bony prominences, maintain proper
preventing injury position
 Absence of throughout the
neurologic, 3. Ensure availability and  to ensure safety and procedure
musculoskeletal, or functionality of equipment smooth conduct of
vascular that would promote the operation  Absence of
compromise safety of the client neurologic,
musculoskeletal,
4. ensure proper - crossed ankles or vascular
positioning cause pressure on compromise
- check neck and spine tissue vessels and
for proper alignment nerves
- check that legs are - hyperextension
straight and uncross can cause injury
ankles to the brachial
- secure arms on padded plexus. Supination
arm boards at less than of palms
90-degree angle from the minimizes
body, palms supnated pressure.

Postoperative Phase
Cues and evidences Nursing diagnosis objectives interventions Rationale evaluation

Subjective: Impaired physical mobility During the postoperative 1. Traction, trochanter  other bodily pain Objectives were fully
 Verbalized, r/t surgical incision phase, the client will rolls, and a firm mattress caused by wrong met as evidenced by:
“maglisod ko ug lihok manifest improved may keep the body in positioning
ug lakaw kung ako ra. physical mobility a/e by: alignment while in bed  Active participation
Kinahanglan jud ko ug  Verbalize willingness in rom exercises and
tabang.” to participate in health teachings
 Verbalized, “Dili activities 2. Have patient perform  ROM exercises are an
pa jud ko pwede maligo active and passive range important part of  Ability to perform
kay mabasa akong  Ability to perform of motion exercises maintaining mobility and activities of daily
tahi.Dili na sad ko ka activities of daily living preventing debilitation. living by herself
dali-dali ug lihok.
Kailangan, hinay-hinay  Gradual return to 3. Explain the value of  encourages  Return of
na jud.” preoperative level of exercises to the patient cooperation and preoperative level of
functioning participation functioning
Objective
 Limited range of  Ability to move about
motion noted comfortably 4. Have patient perform  promotes safety as
 Slowed movement step progression position well as monitored
noted changes progression towards
 Postural instability recovery
during performance of
ADLs noted 5. Demonstrate the  promotes patient
proper use of ambulation learning
devices (wheelchair,
cane)

Postoperative Phase
Cues and evidences Nursing diagnosis objectives interventions Rationale evaluation

Subjective: Pain r/t trauma to the 1. monitor vital signs - to obtain baseline Objectives were fully
 Verbalized, “Sakit operative site During the postoperative data met as evidenced by:
pa jud lihukon phase, the client’s level of - an increase in RR, - vital signs w/in
akong paa.” pain will be decreased a/e PR and BP may normal range
 Rated pain 9 out by: indicate that the T: 37 C
of 10 on a scale of patient is anxious P: 80 bpm, regular
1-10 (With 0-no  development of a pain and in pain R: 18 cpm, regular
pain and 10-most management program and effortless
painful) that includes activity 2. Assess patient’s - correlating patient’s BP: 120/80 mmHg
 Patient and rest schedule, physical symptoms of behavior with activities
complained of exercise program, and pain, physical may be useful in - verbalized,
feeling fatigue medication regimen complaints, and daily modifying tasks “Mawala naman
 verbalization of a activities. ang sakit kung
Objective: decreased level of pain tagaan ko ug
 T: 37 C  rating pain at least 3/10 3. Instruct patient in the - as adjunct to pain tambal.”
P: 80 bpm, on a scale of 0-10 (with use of relaxation medications
regular 0-no pain, 10-most techniques ex. Visual - increases self-help and - Patient actively
R: 18 cpm, painful) imagery, music foster independence participated in the
regular and effortless  absence of facial therapy, relaxation discussion about
BP: 120/80 grimacing, restlessness techniques pain management
mmHg and guarding - to relieve pain and
 Facial grimacing  improvement in mood 4. Teach patient and foster independence - Bantay verbalized,
noted and interaction towards family such “Kabalo raman ko
 Restlessness others techniques as - helps patient gain a mo-masahe.
 Slight perspiration  relaxed and pleasant massage or exercise sense of control & Pwede ako ra
noted facial expression 5. Encourage self-care reduces dependence on magmasahe niya.
 Medications: activities and develop care givers
 Tramadol HCl 50 a schedule - Facial expression
mg IM q 6 H - Tramadol HCl (Tramal) is relaxed and
 Ketorolac 6. Administer Classification: Analgesic pleasant
Tromethamine medications as Action: a centrally active
220 mg q 6 H IM ordered: analgesic that binds to - Absence of
- Tramadol HCl 50 mg IM opioid receptors and grimacing,
q6H inhibits the reuptake of restlessness
norepinephrine and
serotonine, thus - Rated pain 2/10
decreasing pain on a scale of 0-10
(with 0-no pain,
- Ketorolac Tromethamine - Ketorolac Tromethamine 10-most painful)
220 mg q 6 H IM Class: NSAID
Action: has an anit- - Was more active
inflammatory, analgesic in interacting with
and anti-pyretics effect. the bantays
Postoperative Phase
Cues and evidences Nursing diagnosis objectives interventions Rationale evaluation

Subjective: Nutrition Alteration: Less During the postoperative 1. obtain and record - To obtain the most Objectives were fully
 Verbalized, “Gina- than body requirements phase, the client’s patient’s weight everyday accurate readings met as evidenced by:
pugos ko ug kaon sa r/t inability to digest or appetite and food intake
akong mga igsoon absorb nutrients because will increase a/e by: - patient gained 1 lb
pero wa koy gana.” of biological factors - Body weight may
 Verbalized, “Magsakit  patient shows no sign 2. monitor fluid intake and decrease as a result of - calorie intake of patient
man akong tiyan of weight loss output fluid loss is 2000-2300/ day
tungod sa tahi. Basin
3. provide diet prescribed for - common problems of - father verbalized,
mabungkag pag  intake of about 2000
patient’s specific condition. client’s who have “Kailangan jud ka
mukaon ko.” cal daily
Include vitamin B12, folic undergone gastrectomy are mukaon ug gulay kay
 Bantay verbalized. acid, Calcium and vitamin D vit B12 & folic acid daghang bitamina diha.”
“Maski unsaon namo,  communication by the in the patient’s diet. deficiency, calcium
lisod kaayo siya paka- patient and family of metabolism disorders, & - Patient listened and
unon.” understanding of reduced absorption of participated attentively
preoperative calcium & vit D. Such in planning what diet to
Objective: instructions problems result from a follow after discharge
 Appeared weak and shortage of intrinsic factor
pale  communication of the and inadequate absorption - Verbalized, “mukaon na
 Appeared tired and understanding of because of rapid entry of ko ug insakto. Di ko
fatigued special dietary needs food into the bowel ganahan magkasakit
 Has dark circles under balik. Kapoy kaayo.”
the eyes  demonstration of the 4. avoid alcohol and - to avoid the dumping
 Disinterest in ability to plan diet after carbonated drinks & drinks syndrome, a postoperative
surroundings noted discharge that are either too hot or too complication of
 Presence of pressure cold. Chew food slowly. gastrectomy
ulcers
 Pale conjuntiva and 5. monitor bowels sounds - normal active bowel
sounds indicated need for
mucus membranes
feeding. Hyperactive bowel
 Hyperactive bowel
sounds indicate poor
sounds
absorption

6. reinforce medical - collaborative practice

regime by explaining to the enhances patient’s over-all
patient and family the care
reasons for present
regimen

- teach principles of good - This encourages patient

nutrition for the specific and significant others to
condition participate in the patient’s
care

- provide or assist with - increase client comfort

oral hygiene