Name of Patient: __________J.

L_______________ Age/Sex: _____62-F___________ Room/Bed #: _______309-3_________

Chief Complaint: ________Breast Mass______________ Physician: ______Dr. Lim Alexander Uy________
Diagnosis: ___________________________________________________________________________________________________________

Date/ Cues Need Nursing Diagnosis Patient Outcome Planning of Interventions Imple Evaluation
Time ment
ation
F Subjective: C Readiness for within 2 hours of  Establish rapport 1 February 01,2020
E O enhanced coping nursing with the client @
B “ako man gud na P as evidenced by intervention patient R: Enhances comfort and 3pm
R pasyente dili ko ga I positivity towards will: trust, encouraging
U paluya luya kay N treatment. cooperation. GOAL PARTIALLY
A kabalo ko daghan ga G a) verbalize  listen and identify 3 MET
R ampo saakoa” understanding client’s perceptions
Y S R: To determine for the need of of current status.
“ara man ang ginoo T cognitive and the operation. R: It improves mutual After 2 hours of
0 para muguide saatoa” R behavioral efforts to b) Comply with the understanding. To nursing intervention,
1 E manage demands. physician and determine interventions the following data
As verbalized by the S PACU nurse’s needed. were obtained.
2 patient S Ref: order and health  Identify spiritual
0 readiness for teachings beliefs and cultural a) “ingon ni
2 T enhanced Coping. c) Communicates values. doctor Latog
0 Objective: O (n.d.). Retrieved needs and R: It influence sense of naay bukol,
L February 12, 2020, negotiates with hope and connectedness tapos
@  Alert and E from http://nursing- others to meet and give meaning to life. kailangan
1PM cooperative R dx.blogspot.com/20 needs.  explain all 2 dayon
 The patient A 12/01/readiness- procedures ipatanggal,
shows positivity N for-enhanced- thoroughly, mao nag
towards the C coping.html R: Enhances trust and paopera ko.”
treatment E relationship, promoting As verbalized
hope for a positive by the patient
outcome. b) Patient
  Identify ways to nodded when
strengthen the PACU
interactions with nurse
others rendered
R: to support sense of health
belonging and connection. teachings.
 Give relaxation 4 c) “ara man ang
techniques, such as; asawa ko
 Deep breathing para mag
relieves tightness in bantay
the chest wall saakon” as
 Wear comfortable, verbalized by
loose clothing the patient.
R: it’s important to do
exercises afterward with
the consent of the doctor to
get the arm and shoulder
moving again.
 Give exercises
techniques with the
consent of the
doctor as tolerated
such as;
 Use your affected
arm (the same side
as your surgery) as
you normally would
when you comb
your hair, get
dressed, and eat.
 Shoulder rolls and
arm saw
R: They are designed to
improve the
movement of the arm and
shoulders. They should be
done slowly.

Ref:
Nursing Care Plan:
readiness for enhanced
HOPE: Nursing Guide ...
(n.d.). Retrieved February
12, 2020, from
https://mooney6995.typepa
d.com/blog/2012/08/nursin
g-care-plan-readiness-for-
enhanced-hope-nursing-
guide.html

Exercises After Breast

Cancer Surgery. (n.d.).
Retrieved February 12,
2020, from
https://www.cancer.org/can
cer/breast-
cancer/treatment/surgery-
for-breast-
cancer/exercises-after-
breast-cancer-surgery.html