ASSESSMENT
Subjective cues:
 Male
 57 years old
 Post-operative patient
(Operation: March 23, 2021)
 “Masakit yung kanang kamay
ko kasi mali ata yung
pagkakasaksak nung IV.”
 “Sumasakit 'yung sutures
kasi.”
 Abdominal pain: client
verbalizes dull intermittent
pain that has become more
intense.
 Client verbalizes relief of
abdominal pain when lying
supine or sitting up and
bending forward.
Objective cues:
 Weight loss noted.
 Facial grimace noted.
 No further chemotherapy
or treatment planned
 Diagnosed with pancreatic
cancer
 Normal Weight
BMI = 24.9
Height: 170 cm.
Weight: 70 kg.
 Vital signs:
RR = 24/min
Temp. = 37.6 °C
P = 64/min
NURSING DIAGNOSIS
 Risk for Infection related to compromised
host defenses secondary to probable
pancreatic cancer
 Acute Pain related to tissue trauma
secondary to surgery
 Pain (chronic and acute) related to the
effects of tumor invasion and surgical
incision.
PLANNING IMPLEMANTATION RATIONALE EVALUATION
GOAL: The student nurse will:
At the end of the nursing
 At the end of the 1.Instruct the client about the 1. This is done to prevent the intervention, Mr. Sanchez
nursing intervention, Mr. various modes of transmission spread of microorganisms. remains infection-free,
Sanchez will remain of microorganisms and risk report pain is relieved/
infection-free, report factors. controlled, follow
pain is relieved/ prescribed therapeutic
controlled, follow 2. Enumerate to the individual 2. This is done for the client to be regimen, and demonstrate
prescribed therapeutic and family members the signs able to assess herself for use of methods that
and symptoms of infection. provide relief.
regimen, and possible infection and inform the
demonstrate use of nearest health professional and
methods that provide be given immediate care. (GOAL MET)
relief.
3. Use strict aseptic technique 3. Limits sources of infection,
when changing surgical which can lead to sepsis in a
dressings or working with IV compromised After the nursing
OBJECTIVES: lines, indwelling catheters and patient. Note: Studies indicate intervention, Mr. Sanchez is
tubes, drains. Change soiled that infectious complications are able to:
After the nursing dressings promptly responsible for about 80% of
intervention, Mr. Sanchez deaths associated with 1. Describe 2 methods of
will: pancreatitis. transmission of infection.
1. Describe 2 methods of 4. Observe rate and 4. Fluid accumulation and limited 2. Verbalize understanding
transmission of infection. characteristics of respirations, mobility predispose to respiratory of individual/causative risk
breath sounds. Note occurrence infections and atelectasis. factors in his own words.
2. Verbalize of cough and sputum production Accumulation of ascites fluid may
understanding of cause elevated diaphragm and 3. Describe the influence of
individual/causative risk shallow abdominal breathing. nutrition on prevention of
factors in his own words. infection in his own words.
5. Encourage frequent position
3. Describe the influence 5. Enhances ventilation of all lung 4. Maintain adequate
changes, deep breathing, and
of nutrition on prevention segments and promotes hydration.
coughing. Assist with
of infection in his own mobilization of secretions
words. ambulation as soon as stable. 5. Demonstrate meticulous
hand washing procedure.
4. Maintain adequate 6. Promote position of comfort 6. Reduces abdominal
hydration. on one side with knees flexed, pressure and tension, providing
6. Perform preoperative
sitting up and leaning forward. some measure of comfort and
BP = 120/60 5. Demonstrate pain relief. Note: Supine position body shower or scrubs when
meticulous hand washing often increases pain. indicated.
 Latest hematology results: procedure.
(March 21, 2010) 7. Demonstrate proper deep
Decreased RBC, Hgb and Hct. 6. Perform preoperative 7. Provide alternative comfort 7. Promotes relaxation and breathing exercises,
RBC = 2.93 x 10 ^12/L body shower or scrubs measures (back rub), enables patient to refocus coughing technique and
Hgb: 98 g/L when indicated. encourage relaxation technique attention; may enhance coping. ROM exercises.
HCT: 0.292 s (guided imagery,
7. Demonstrate proper visualization), quiet diversional (GOAL MET)
 Increased Neutrophils and deep breathing exercises, activities (TV, radio).
WBC. coughing technique and
 Neutrophils = 0.896 ROM exercises. 8. Keep environment free of 8. Sensory stimulation can
 WBC = 12.10 10^9/L food odors. activate pancreatic enzymes,
 Antibiotic Therapy increasing pain.
(Metronidazole 1cap TID x 2
days)
 NSS infused at 31 gtts at right 9. Administer medication as 9. Meperidine is usually effective
arm, (+) inflammation indicated: Narcotic in relieving pain and may be
analgesics: meperidine preferred over morphine, which
(Demerol), can have a side effect of biliary-
pancreatic spasms.

References:

 Doenges, M., Moorhouse, M. F. & Murr, A. (2006). Nurse’s pocket guide: Diagnoses, prioritized interventions and rationales. Philadelphia: F.A. Davis
 Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004). Fundamentals of nursing (7th ed). Philippines: Pearson Prentice Hall
 Smeltzer, S & Bare, B. (2004). Medical-surgical nursing. N.p.: Lippincott Williams & Wilkins