V.

NURSING MANAGEMENT

PRE-OPERATIVE NURSING CARE PLANS

Problem # 1: Acute Pain

Nursing Scientific Nursing Expected

Assessment Objectives Rationale
Diagnosis explanation Interventions Outcome

S= ᴓ Acute pain  The presence of Short term:  Establish  To gain Short term:
related to bowel a tumor creates After 4 hours of rapport patient’s trust The pain shall
O=Patient distension an obstruction in nursing have been
manifested: secondary to the colon and interventions, the  Assess the  To obtain minimized as
disease condition because of this patient’s pain will patient’s baseline data evidenced by an
 Limited mechanical be minimized as condition and to plan for absence of facial
movements obstruction or evidenced by an the appropriate grimaces and
fecal impaction, care restlessness and
 Body malaise absence of facial
there is an grimaces and a decrease in pain
 Guarding
impairment of flow Assess vital  Alteration in from 6/10 to 2/10.
restlessness and
behavior signs. Vital signs is
in the intestinal a decrease in pain
 facial contents of the GI. from 6/10 to 2/10.
evident in the Long Term:
grimaces This would presence of pain The patient shall
 crying activate the Long Term: Assess  To obtain have been
 irritability secretory cell After 3 days of patient’s degree information about relieved from pain
 increased activity, releasing nursing of pain every time the pain that the and will have vital
fluid and air which interventions, the she verbalizes patient is signs within
vital signs
would then collect patient will be pain manifesting normal limits.
especially BP
to the proximal relieved from pain
site of the and will have vital

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 obstruction. As a signs within
result, fluid and air normal limits.
 P- movement accumulation
occurs and thus
distension occurs. Reposition  Serves as a
This distension patient comfort measure
Q- sharp
would then cause  To decrease
R- mid  Provide quiet
pressure and environment
abdomen environment
irritation of the stimulus and
nerve endings promote rest
S- pain scale within the
of 6/10 intestinal mucosa  Provide  To alleviate
T-every time comfort feeling of pain
movement is measures
 To lessen
elicited
 Advise the pain
patient may patient to deep
manifest: breathing
exercises.
 To lessen
 perspiration
 Encourage pain by allowing
 signs and patient to do the patient to
symptoms of diversional focus on other
inflammation activities such as things
at surgical watching TV or
site talking to a family
 moaning, members
shouting,  Provides
sighing  Administer pharmacologic
analgesics as treatment to
prescribed lessen patients
pain

Problem # 2: Mild Anxiety

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 Nursing Scientific Nursing Expected
Assessment Objectives Rationale
Diagnosis explanation Interventions Outcome

S= ᴓ Anxiety related to Fear of the Short term:  Assess To know the Short term:
threat of death unknown is the After 4 hours of patient’s patient’s The patient’s pain
O=Patient and possible most prevalent nursing general condition and shall have used
manifested: complications causes of interventions, the condition provide resources and
after surgery preoperative patient’s pain will necessary support system
 Restlessness anxiety. The use resources actions and effectively.
 Irritability patient and support interventions.
 Increased experienced a system effectively. Long Term:
perspiration vagua uneasy To obtain The patient shall
 Monitor and baseline data
 Anorexia feeling of Long Term: have appeared
record vital
 Insomnia discomfort or After 4 days of relaxed and
signs
 dread nursing reported anxiety is
accompanied by interventions, the  Observe the This can be a reduced to a
an autonomic patient will appear patient’s clue to the manageable level.
response. A relaxed and report behaviour patient’s anxiety
feeling of anxiety is reduced indicative of level
patient may
apprehension to a manageable level of anxiety.
manifest:
caused by level. To determine
anticipation of  Identify the those that might
 perspiration
patient’s coping
danger in surgery. be helpful in
skills and current
It enables the review coping circumstances
 signs and client to take skills in the
symptoms of measures to deal past.
inflammation with the threat.
at surgical  Establish a To assist patient
site therapeutic to identify
relationship, feelings and
conveying begin to deal
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 moaning, empathy and with problems.
shouting, unconditional
sighing positive regard.

 Acknowledge Do not deny or

anxiety or fear. reassure patient
that everything
will be alright

 Provide Helps patient to

accurate identify what is
information reality based
about the
situation

 Provide comfort To limit degree

measures such of stress.
as providing Helpful in
calm/quiet reducing level of
environment, anxiety by
soft music and relieving tension
back rub.

Problem # 3: Risk for Fluid Volume Deficit

Assessment Nursing Scientific Objectives Nursing Rationale Expected

74
 Diagnosis explanation Interventions Outcome

S- ᴓ Risk for fluid Normally, the bowel Short term:  Assessed To obtained Short term:
volume deficit secretes 7-8 L of After 5 hours of patients baseline data The patient shall
O- patient related to electrolyte-rich fluid, nursing overall status for future have been
manifested: vomiting and most of the interventions, references relieved from
decreased fluid is absorbed. patient will be vomiting.
Vomiting intestinal When the bowel is relieved from  Monitor and To obtain
Abdominal reabsorption of obstructed by a vomiting. record vital baseline data Long term:
distension fluid and tumor, this fluid is signs The patient shall
decreased partially retained Long term: have been
intestinal within the bowel After 3 days of  Monitor intake To ensure maintained a
Patient may secretions and partially NPI the patient and output accurate volume at a
manifest: secondary to eliminated by will maintain picture of functional level
disease vomiting causing volume at a fluid status. as evidenced by
Dehydration condition severe reduction in functional level individually
Hypotension circulating blood as evidenced by  Auscultate To assess adequate
Hypovolemic volume which may individually bowel sounds the quality of urinary output
shock result in adequate bowel with normal
hypotension, urinary output sounds. A specific gravity,
hypovolemic shock with normal lack of bowel moist mucous
and diminished real specific gravity, sounds membranes,
and cerebral blood moist mucous indicates good skin
flow. membranes, peritoneal turgor, and
good skin irritation prompt capillary
turgor, and refill.
prompt capillary  Observe for To make
refill. signs of necessary
dehydration interventions.

 Establish To correct the

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 individual deficit
needs/replace
ment schedule

 Provide  To prevent
supplemental peaks and
fluids as valleys in fluid
indicated level

 Provide small  To maintain

frequent the nutritional
feedings needs of the
patient

 Administer  To reduce
anti-emetic patient’s
medications vomiting
as ordered. episodes.

INTRA OPERATIVE NURSING CARE PLANS

Problem # 1: Risk for Infection
Assessment Nursing Scientific Objectives Nursing Rationale Expected
76
 Diagnosis explanation Interventions Outcome

Risk for Surgery is performed Short term:  Implements To maintain a Short term:
S= ᴓ infection using aseptic After 4 hours of aseptic sterile field The patient’s
technique and in a nursing technique. during the surgery shall
O=patient may manner to prevent interventions, the operation have been
manifest: cross contamination. patient’s surgery performed using
During the operation, is performed  Classifies To know to the aseptic
 signs and a surgical incision using aseptic surgical preventive technique and
symptoms of must be made. technique and in wound. measures to be in a manner to
inflammation Breaks in the a manner to taken prevent cross
at surgical site integument, the prevent cross contamination.
body’s first line of contamination.  Assesses To be able to
 increase defense, and/or the susceptibility administer Long Term:
in vital sign mucous membranes Long Term: for infection. prophylactic The patient
allow invasion by After 5 hours of treatment shall have been
 signs and pathogens. If the nursing free of signs
symptoms of patient’s immune interventions, the  Performs skin Ensures that and symptoms
shock system cannot patient will be free preparations. lessening of risk of infection.
combat the invading of signs and for infection
organism adequately, symptoms of
an infection occurs. infection.  Monitors for To enable
Open wounds, signs and proper and early
traumatic or surgical, symptoms of management of
can be sites for infection. signs and
infection during and symptoms
after an invasive
procedure.
 Minimizes the To lessen
length of occurrence or
invasive possibility of
procedure trauma and
planning care. infection
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  Administers To provide
prescribed pharmacological
prophylactic management for
treatments. infection

 Administers To minimize

care to wound exposure of
sites. wounds to
microorganisms

Problem # 2: Risk for Impaired Skin Integrity Related to Positioning, Immobilization, Pressure or Shearing Forces

Nursing Scientific Nursing Expected

Assessment Objectives Rationale
Diagnosis explanation Interventions Outcome

78
S= ᴓ Risk for Immobility, Short term:  Identifies  To determine Short term:
impaired skin which leads to After 4 hours of physical extent of The patient’s
O=patient may integrity related pressure, shear, nursing alterations adjustment skin shall have
manifest: to and friction, is interventions, that may when remained
positioning, the factor most the patient’s skin affect performing smooth, intact,
 signs and immobilization, likely to put an remains smooth, procedure- positioning non-reddened,
symptoms of pressure, individual at risk intact, non- specific non-irritated, and
inflammation and/or shearing for altered skin reddened, non- positioning. free of bruising,
at surgical forces integrity. irritated, and free  To ensure other than
site Advanced age; of bruising, other  Positions the that the surgical incision.
the normal loss than surgical patient. patient is
 increase of elasticity; incision. comfortable Long Term:
in vital sign inadequate and position The patient shall
nutrition; Long Term: is appropriate have been free
 Pressure potentiate the After 5 hours of for the of signs and
sores effects of nursing procedure symptoms of
pressure and interventions,  Implements physical injury.
hasten the the patient will protective  To avoid
 Redness development of be free of signs measures to trauma from
or blemishes skin breakdown. and symptoms prevent skin external
Improper of physical or tissue forces in the
positioning and injury. injury due to environment
surgical thermal,
management chemical, or
during the mechanical
operation can sources.
predispose the
occurrence of  Evaluates for  To observe
disruption of skin signs and for any
integrity thus symptoms of alterations in
management injury to skin skin integrity
must be done to and tissue.
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 minimize such.
 Evaluates for  To provide
signs and prompt
symptoms of management
injury as a of identified
result of signs and
positioning. symptoms

Problem #3: Risk for Hypothermia

Nursing Scientific Nursing Expected
Assessment Objectives Rationale
Diagnosis explanation Interventions Outcome

Risk for Hypothermia Short term:  Implements  To prevent a Short term:

S= ᴓ hypothermia occurs when the After 4 hours of thermoregulati decrease in The patient’s
body’s core nursing on measures. body core body
O=patient may temperature falls interventions, temperature temperature
manifest: below its normal the patient’s shall have
level of 98.6°F to core body  Monitors body  To monitor remained within
 Chills
95°F or colder. temperature will temperature. patients core expected range.
 Cold It is the opposite remain within temperature
clammy skin of fever, when expected range. Long Term:
 Decrease in the body’s  Evaluates  To perform The patient shall
vital signs temperature is Long Term: response to appropriate have been at or

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 Cyanotic nail above normal. After 5 hours of thermoregulati measures returned to
beds The operating nursing on. and normothermia at
 Tremors room must be interventions, management the conclusion
kept in a certain the patient will of the immediate
 Hypotension temperature to be at or return to  Perform  Increases in postoperative
 Rapid and reduce the normothermia at insulation ambient period.
weak pulse growth of the conclusion measures like temperature
microorganisms of the immediate warming are used to
and prevent the postoperative blankets, keep the
build up of period. socks, head peripheral
moisture. With covering and tissue closer
that, the room is other apparel to target
maintained in a temperatures
cool
temperature.
This in turn
predisposes the
patient in to  Warming of IV  Significantly
experiencing fluids as reduces the
hypothermia ordered impact of
because of vasodilation
his/her and
environment. redistribution
Hypothermia is hypothermia
dangerous
because it
affects the
body's core –
the brain, heart,
lungs, and other
vital organs.
accidents.
Severe

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 hypothermia
causes loss of
consciousness
and may result
in death.

POST OPERATIVE NURSING CARE PLANS

Problem # 1: Acute Pain R/T Disrupted Skin Integrity, Damaged Tissues and Nerves
Nursing Scientific Nursing Expected
Assessment Objectives Rationale
Diagnosis explanation Interventions Outcome

S= “kumikirot Acute pain r/t Pain is an Short term:  Establish  To gain Short term:
ung tahi ko sa disrupted skin expected After 4 hours of rapport patient’s trust The pain shall
tiyan”. as integrity, outcome post- nursing have been
verbalized by the damaged tissues operatively. And interventions,  Assess the  To obtain minimized as
pt. and nerves because pain is the patient’s pain patient’s baseline data evidenced by an
intensified with will be minimized condition and to plan for absence of facial
O=Patient movement as evidenced by the appropriate grimaces and
manifested: increase in an absence of care restlessness and
discomfort is facial grimaces a decrease in
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 facial exhibited. Due to and restlessness Assess vital  Alteration in pain from 6/10 to
grimaces the presence of and a decrease signs. Vital signs is 2/10.
 crying a surgical in pain from 6/10 evident in the
incision, to 2/10. presence of Long Term:
 irritability continuity in the pain The patient shall
 increased integrity of the Long Term: have been
vital signs skin is After 3 days of  To obtain relieved from
Assess information
especially interrupted. The nursing pain and will
patient’s degree about the pain
BP abundance of interventions, have vital signs
of pain every that the patient
 P- nerve endings in the patient will time she within normal
movement the skin makes it be relieved from is manifesting limits.
verbalizes pain
Q- sharp very sensitive to pain and will
pain stimuli. have vital signs  Serves as a
Reposition comfort
R- mid Trauma such as within normal patient
abdomen S- cuts and limits. measure
pain scale of incisions in
6/10 invasive
procedures post  Provide quiet  To decrease
T-every time operatively, the environment environment
movement is release of stimulus and
elicited nociceptors that promote rest
transmit pain  Provide
patient may
stimuli and there comfort  To alleviate
manifest:
is the release of measures feeling of pain
chemicals such
 perspiration
as histamine,  Advise the
 signs and bradykinin and patient to deep
symptoms of  To lessen
prostaglandin breathing
inflammation pain
that contributes exercises.
at surgical to the
site experience of  Encourage
moaning, pain.  patient to do  To lessen
shouting, sighing diversional pain by

83
activities such allowing the
as watching TV patient to focus
or talking to a on other things
family members

 Administer
analgesics as  Provides
prescribed pharmacologi
c treatment to
lessen
patients pain

84
Problem # 2: Risk for Spread of Infection r/t Inadequate Primary Defenses (Broken Skin, Traumatized Tissue)

Nursing Scientific Expected

Assessment Planning Intervention Rationale
Diagnosis Explanation Outcome

S= ᴓ Risk for There are normal Short Term:  Observe aseptic  To prevent Short Term:
spread of flora residing in After 4 hours of techniques when the spread of The risk for
infection r/t our skin and nursing handling the microorganis infection shall
inadequate these interventions, patient. ms, proper have been
O= Pt. may primary microorganisms the client will be washing is a minimized
manifest: defenses are opportunistic free from first line of
(broken skin, in nature. As a infection. defense Long Term:
 with wound traumatized result of the against The patient
dressing tissue) disruption in the nosocomial shall have no
skin integrity, Long Term: infection. infection AEB
these After 3 days of  Instruct patient WBC within
microorganisms nursing to avoid  It may normal range
may cause an interventions, touching wound predispose
May manifest:
increased risk to the patient shall with bare hands. the
infection due to get rid or there occurrence of
the break in the shall be a total infection since
 drainage in continuity of the elimination of the hands are
the surgical skin, the body’s risk for also carrier of
site. first line of infection. microorganis
defense. This ms.
 Increased disruption serves  Provide sterile
as a portal of  Prevent
WBC count dressing environmental
entry for
microorganisms. contamination
of fresh
 soiled
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 dressing wounds

 Encourage  To prevent
 redness of patient to possible
affected increase fluid recurrence of
area intake infection

 presence of  Administer  To provide

pus at the antibiotics as pharmacologi
surgical ordered cal treatment
incision

 swelling of
affected
area

 skin is warm
to touch at
the affected
area

Problem # 3: Risk for Aspiration Related to Impaired Swallowing Due to Previous Placement of Nasogastric Tubing
86
 Nursing Scientific Nursing Expected
Assessment Objectives Rationale
Diagnosis explanation Interventions Outcome

Short term:  Assessed  To obtained Short term:

S- “Minsan, Risk for To prevent After 4 hours of patients overall baseline data for The patient
nahihirapan aspiration aspiration and gas NPI the patient status future will
akong lumunok” related to distension, a NGT will demonstrate references. demonstrate
impaired is placed. When techniques to techniques to
prevent  Noted amount  to monitor prevent
swallowing this tube is
aspiration such and rate of food patients daily aspiration
O- patient due to inserted and as sitting upright and fluid intake intake. such as
manifested: previous removed, the and eating from all sources sitting upright
placement of tubing leads to slowly. and eating
coughing after nasogastric trauma of the  Placed in semi  To facilitate slowly.
drinking tubing esophagus, Long term: fowlers position as movement of
making it difficult After 3 days of appropriate diaphragm, Long term:
shortness of NPI the patient improving The patient
for the patient to
breath and will be free from respiratory effort will be free
swallow properly. aspiration. from
easy Aspiration  Advise the  To facilitate aspiration.
fatigability happens when patient to maintain swallowing
when eating food, liquid, or any an upright position
material blocks or when eating.
needs
assistance enters the air
 Encourage the  To allow proper
when drinking passages, leading client to eat food breaking down of
and eating to compromised and drink more food for easy
breathing. slowly swallowing.

Problem # 4: Activity Intolerance Related to Generalized Weakness

87
 Nursing Scientific Nursing Expected
Assessment Objectives Rationale
Diagnosis explanation Interventions Outcome

S- “Nanghihina ako Activity Activity Short term: Assess pt’s  To obtained Short term:
lagi” as verbalized by intolerance intolerance is a After 4 hours condition baseline The patient
the pt. related to condition of the of NPI the data for shall have used
generalized body where patient will be future and identified
weakness there is able to use references. techniques to
insufficient and identify enhance
O- patient physiological or techniques to  To identify activity.
manifested: Note the pt’s
psychological enhance report of more
 weak posture means or activity weakness, causative or
capability to fatigue or precipitating Long term:
endure or difficulty factors The patient
 inability to complete the accomplishing shall have
maintain required or Long term: tasks demonstrated a
balance desired daily After 3 days of measurable
activities. NPI the patient Provide  To prevent increase in
Depression can will adequate rest fatigue activity.
 pale be one of the demonstrate a periods
factors that may measurable
increase or increase in Increase activity  To conserve
 slow contribute to activity. levels gradually energy
movement general
weakness and Assist the pt in  To protect
may lead to doing her ADL’s the pt from
 limited range injury
inability of the
of motion
person to
participate in
 discomfort the activities of
daily living. Promote comfort  To enhance
Tolerance to ability to
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  decreased activity wil be measures participate in
levels of compromised activities
potassium for a patient
experiencing a  To indicate
disease Monitor the need to
condition. responses to the alter activity
activity level

Encourage pt to  To promote
change position wellness and
frequently proper
circulation

 To treat
Administer underlying
medication as factors
ordered

Problem # 5: Anxiety Related to Lack of Knowledge about the Disease Condition

89
 Nursing Scientific Expected
Assessment Planning Intervention Rationale
Diagnosis Explanation Outcome

S = “Ano naba Anxiety Anxiety is a Short Term:  Establish  To gain clients Short Term:
nyan ang related to lack vague uneasy rapport trust and
mangyayari of knowledge feeling of After 3 hours of participation The patient
sakin.?” as about the discomfort or Nursing shall have
verbalized by the disease dread Interventions  Assess pt’s  To obtain identified ways
pt. condition accompanied by the patient will condition baseline data to reduce
an autonomic be able to anxiety.
O= Patient response or a identify ways to  Assess for  In order to
manifested feeling of reduce anxiety. level of anxiety know the
apprehension manageability
Restlessness caused by of anxiety and
Appears tense anticipation of provide
High blood Long Term: Long Term:
danger. Due to appropriate
pressure the lack of intervention Patient shall
After 2 days of
knowledge about Nursing have
Patient may the disease Interventions  Explain to the  Limited demonstrated
manifest: condition, the patient will patient, what knowledge of reduction of
patient is not demonstrate to expect the unknown anxiety into
 Increased RR aware or is reduction of results may manageable
having difficulty anxiety into cause anxiety levels
 Muscle adjusting about to the patient
manageable
tension the levels
 Diaphoresis manifestations of  Teach the pt  Deep
the disease. proper breathing
Thus the patient breathing exercises can
is afraid on what exercises reduce
will happen to her tension
condition as the
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disease  Instruct the  To divert
progresses. patient to do focus to other
diversional things
activities

 Collaborate  Collaboration
with other promotes the
professionals best long
range plan to
attain success
for the health
of the patient

 Administer anti  Helps to relax

anxiety drugs the patient if
as ordered necessary
and
uncontrollable

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