MAÑALAC, EUNICE JADE A.

BSN 3-A

Pre-Operative (Incision & Drainage of Abscess)

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Acute pain r/t After 4 hours of INDEPENDENT: After 4 hours of

disease process nursing nursing
AEB palpable intervention, the ● Monitor ● To have intervention, the
fluctuant patient will vital signs. baseline patient appears
abdomen and appear relaxed data and to relaxed and
Objective: swelling and verbalize monitor verbalized pain
- Pain Scale pain scale from progress. scale from 9/10 to
of 9/10 9/10 to 6/10. 8/10.
- Guarding ● Assess and ● Changes in
behavior record these vital Goal partially
- Restlessne character, signs often met.
ss onset, indicate
- Agitation location, acute pain
- WBC 11 intensity of and
pain. discomfort

● Maintain a ● To
calm and minimize
quiet stimulus
environme that could
nt. aggravate
the
condition
MAÑALAC, EUNICE JADE A.
BSN 3-A

of the
patient.
● Encourage ● Relieves
use of muscle and
relaxation emotional
techniques tension;
: deep enhances
breathing sense of
exercises. control
and may
improve
coping
abilities.

DEPENDENT:
● Administer ● Analgesics
analgesics given IV
as reach the
prescribed pain
by the centers
physician. immediatel
y,
providing
more
effective
relief with
small
doses of
MAÑALAC, EUNICE JADE A.
BSN 3-A

medication
.
MAÑALAC, EUNICE JADE A.
BSN 3-A

Intra-operative

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Impaired skin After 6 hours of ● Health ● Protects After 6 hours of

integrity r/t nursing teaching wound nursing
altered intervention, the about from intervention, the
circulation, patient will dressing mechanical patient
accumulation of demonstrate and change injury and demonstrated
drainage AEB behaviors to as contaminat behaviors of
disruption of skin promote healing indicated ion. healing and
Objective: surface/layers and to prevent use strict Prevents preventing
- Palpable and tissues. complications. aseptic accumulati complications.
fluctuant techniques on of fluids
abscess that may
- For I&D cause Goal met.
(Incision & excoriation
Drainage)
● Can impair
● Check or occlude
tension of circulation
dressings. to wound. .
Apply tape
at center of
incision to
outer
MAÑALAC, EUNICE JADE A.
BSN 3-A

margin of
dressing. ● Early
● Inspect recognitio
wound n of
regularly, delayed
noting healing or
characteris developing
tics and complicati
integrity. ons may
prevent a
more
serious
situation.

● Decreasing
● Assess drainage
amounts suggests
and evolution
characteris healing
tics of process.
drainage.
MAÑALAC, EUNICE JADE A.
BSN 3-A

Post-Operative

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Readiness for After 9 hours of ● Verify ● Provides After 9 hours of

enhanced nursing client’s opportunit nursing
therapeutic intervention, the level of y to assure intervention, the
management patient will understan accuracy patient remained
remain free of ding of and free of
Objective: preventable therapeuti completen preventable
- BP: complications/pr c regimen. ess of complications/pr
110/90mm ogression of Note knowledge ogression of
Hg illness. specific base for illness.
- HR: 97 health future
- RR: 19 goals. learning.
- TEMP.: 36.2 ● Identify ● Understan Goal met.
- 02SAT%: steps ding the
99% necessary process
- Pain Scale to reach enhances
of 4/10 desired commitme
health nt and the
goals. likelihood
of
achieving
the goals.