ASSESSMENT DIAGNOSIS PLANNING INTERVERTION RATIONALE EVALUATION

After 1 to 2 hours of Independent: The client’s level of pain

SUBJECTIVE: Acute Pain related nursing intervention >monitored vital signs >serve as a baseline data was minimized as
“Nakakaramdam ako to incision site the client’s feeling of >monitor and document >variation of appearance evidenced by decreased
ng kirot sa aking manifested by pain will be characteristic of pain, noting and behavior of client’s pain scale from 6 to 3.
kaliwang tagiliran “ observed minimized/reduced verbal and non-verbal cues pain may present a
as verbalized by the guarding behavior to a tolerable level. change in assessment
patient” in bed. >obtain full description of pain >pain is subjective
from client including location, experience and must be
intensity, duration, describe by client
characteristic and radiation
OBJECTIVE: >Provide comfort measures >To promote relief and
such as use of pillows under wellness.
Vital Signs: extremities and periodic
BP – 120/80 wound cleaning on affected
PR – 87 bpm area.
RR – 32 >Encourage and assist client >Deep breathing
breaths/min to do deep breathing exercises contribute to
Temp – 37.4 exercises. relief of pain
(+)stabbing pain
left lower quadrant > Teach client and significant >To maximize
of the abdomen other about the non- opportunities for self-
Pain scale- 5-6 pharmacologic ways to control over pain
(+) facial grimace lessen the pain. manifestations.
> Instruct client to report any >Only the client can
>(+)difficulty in improvement/exacerbation in judge the level and
turning pain experience. distress of pain;
>(+)observed the abdomen for bowel pain management
guarding behavior sounds should be a team
in bed approach that
Dependent: includes the client.
>Administer medications, >To manage the pain of
particularly analgesics, as the client
prescribed.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Risk for infection After an hour of Independent: - Indicators of sepsis After an hour of
SUBJECTIVE: related to nurse patient 1. Monitor vital requiring prompt nurse patient
“Nahihirapan akong periodic interaction he signs for fever. evaluation and interaction the patient
gumalaw dahil sa catheter catheterization . patient will be able able to verbalized
intervention.
na nakakabit sa akin.” (As
to verbalize - to maintain renal understanding the
verbalized by the paient)
understanding the 2. Encourage function and prevent importance of
importance of increase fluid development of catheterization..
catheterization. intake infection
- Prevents cross-
OBJECTIVE: 3. Emphasize good contamination;
hand washing reduces risk of
Vital Signs: technique for all acquired infection
BP – 120/80 individuals coming
PR – 87 bpm
in contact with - reduces risk of
RR – 32 breaths/min
Temp – 37.4 patient. ascending
4. Encourage infection
>Pt. seen with an meticulous
indwelling Catheter and
- Prevents
catheter perineal care
exposure to
connected with 5. Provide sterile or
infectious Organisms.
the urine bag freshly laundered
- Prevents cross-
>(+)body linens/gowns.
contamination from
malaise 6. Monitor/limit
visitors.
>(+) pale looking visitors, if
necessary.
Dependent:
-Reduces bacteria
7. Administer
present in urinary tract
antibacterial as
and those introduced
ordered.
by drainage system.