Assessment Diagnosis Planning Interpretation Evaluation

Subjective: Acute pain related to After 1 day of nursing Independent: After 1 day of nursing
Patient verbalized: incision site as manifested intervention, the patient 1. Respond intervention, the patient
“masakit ang bandang by observed guarding will be able to relief of immediately to was able to relieved of
operasyon ko kapag behavior when moved to pain as evidence by complaint of pain. pain as evidence by
bumabangon ako” bed with v/s of T= 36 P=79 absence of guarding 2. Instruct patient to absence or guarding
R= 18 BP=100/70. behavior when moved. report pain behavior when moved.
Objective: 3. Provides rest
Observed guarding periods. Goal met.
behavior when moved to 4. Instruct patient in
bed. use of relaxation
T= 36 exercises.
P=79 Dependent:
R= 18 1. Give analgesic s as
Bp= 100/70 ordered,
evaluating
effectiveness and
observing for any
signs and
symptoms of
untoward effects.
Assessment Diagnosis Planning Intervention Evaluation
Subjective: Impaired physical mobility After 1 day or nursing Independent: After 1 day of nursing
Patient verbalized: related to pain or intervention the patient 1. Assess degree or intervention the patient
“nahihirapan akong discomfort as manifested will be able to maintain or pain, listening to was able to maintained or
gumalaw “ by verbal report difficulty increase strength and client’s increased strength and
turning, slowed movement function of affected and or description. function of affected and or
Objective: with v/s of T=36, P=79, compensatory body part. 2. Schedule activities compensatory body part.
>difficulty turning R=18, BP=100/70 with adequate rest
>slowed movement periods during the Goal met.
T=36 day to reduce
P=79 fatigue.
R=18 3. Demonstrate use
Bp=100/70 of standing aids
and mobility.
Dependent:
 Administer
medications prior
to activity as
needed for pain
relief to permit
maximal
effort/involvemen
t in activity.
Asses sment Diagnosis Planning Intervention Evaluation
Objective: Potential infection related After 1 day of nursing Independent: After 1 day of nursing
 With incision on to present of SI incision. intervention the patient 1. Change dressing intervention the patient
the lower will be able to remain free as often as was able to remained free
quadrant of the from infection as evidence necessary and as from infection as
abdomen. by normal vital signs, always use to evidenced by normal vital
absence of redness, sterile technique signs, absence of redness,
edema and pain at the 2. Monitor vital signs edema and pain at the
incision site. of infection. incision site.
3. Assess nutritional
status, including
weight history of
weight loss and
serum albumin
4. Wash hands
before contact
with patient and
between
procedures with
patient.
5. Encourage in
intake of protein
and calorie-rich
food.