ASSESSMENT NURSING GOALS AND NURSING EVALUATION

DATA DIAGNOSIS OBJECTIVES INTERVENTIO

NS AND
RATIONALE

Subjective: Acute Pain related Short-term Goals: Independent: Goals partially met
to surgical incision After 8 hours of after 8 hours of
May 24, 2023 secondary to nursing interventions, 1. Note type nursing interventions
(Postoperative Excision of the patient will: and location as evidenced by:
Day 1) Choledochal Cyst of incision
and and drainage.
 
Hepaticoduodenos Rationale:
 tomy and insertion Severe pain in
of Jackson-Pratt verbalize either area patient
“Sakit (JP) drain (May 24 pain within should be reporting
kaayo to 26, 2023: manageab investigated that pain
ang Postoperative le level further for was slightly
kaning Days 1 to 3) and will possible relieved
dapit sa report a complications from a pain
gi opera decrease scale of
sa ako, in pain 10/10 to
2.Perform and
mura ko scale 9/10
document a
og rating
comprehensi
gidungga from
ve 
b sa 10/10 to
continuous 
kasakit. 8/10
pain
Nag sige assessment.
ko og patient
 Instruct
mata patient in participatin
 g in actions
gabii, dili regular use of
ko a (0–10 or to decrease
katulog participate similar) pain- pain and
og tarong in actions rating scale. demonstrat
tungod to Monitor pain ed proper
sa ka decrease scale rating at use of non-
sakit,” as pain regular pharmacolo
verbalize intervals. gic comfort
d by the Rationale: measures 

patient Assists in such as
on the  comfortable
differentiating
first cause of pain positioning
postoper demonstra and provides and
ative day te proper information splinting
use of about disease when
adjunct progression or moving and
 comfort performing
 resolution,
measures development deep
of breathing
Pain complications, exercises

scale and
10/10; effectiveness 
sharp Long-term Goals: of
stabbing interventions.A
After 4 days of
pain felt standardized
nursing interventions, Goals met after 4
at the tool for rating
the patient will: days of nursing
right pain helps in
upper assessment interventions as
and lower  and evidenced by:
quadrant management
s of the of pain 
report that
abdomen
pain is
decreased 3. Regularly patient
 or monitor and reporting
controlled investigate if that pain
through a there are was
May 25, 2023
(Postoperative decrease reports of controlled
Day 2) in pain increased from a pain
scale incisional scale of
rating pain and 10/10 to

from changes in 4/10
greater characteristic
“Sakit  pa than 5/10 s of pain.
gihapon 
to less Rationale:
akong than 5/10. Deep, dull, 
tahi og aching pain in
kini pud the operative patient
dapit sa 
area may appearing
drain nga  indicate relaxed and
nakasabit developing gets
sa akong appear infection. uninterrupt
tiyan, relaxed ed longer
wala pa and able 4. Position JP sleep at
gihapon to rest and drain night
ko’y sleep accordingly
tarong appropriat for optimal
nga 
ely. function;
tulog,” as making sure 
verbalize tubing is not
d by the 
kinked and is patient
patient  free from demonstrati
on the clots or any ng normal
second demonstra obstructions. vital signs:
postoper te age- Secure the BP: 120/80
ative day appropriat bulb to keep mmHg; PR:
e blood it from pulling 62 bpm;
 pressure on the skin or RR: 18
(BP), becoming cpm

pulse, and dislodged.
respiratory Drain
Pain 
rates. accumulated
scale fluid as 
10/10; necessary.
sharp 
Rationale: patient not
pain felt  Improper manifesting
at the at position, guarding
the right manifest kinking, or behaviors,
upper decreased accumulation was not
and lower or of clots and restless,
quadrant absence fluid in the was smiling
s of the of tubing and was
abdomen guarding changes the not irritable
behaviors, desired anymore
 restlessne negative
ss, and pressure and
impedes air or

irritability.
May 26, 2023 fluid 
(Postoperative evacuation
Day 3) 
 patient
 demonstrati
 ng proper
demonstra use of non-
te use of pharmacolo
“Dili na
relaxation gic comfort
kaayo
skills and measures 
sakit
diversiona such as
akong
l activities comfortable
tahi pero
and on positioning
sakit pa
non- and
gihapon
pharmacol splinting
ni ang
ogic and
dapit sa
 drain nga methods performing
nakasabit to control deep
sa akong pain. breathing
tiyan,” as exercises
verbalize

d by the
 
patient
on the 
third participate
postoper in usual patient
ative day activities participatin
of daily g in usual
living  activities of

(ADLs) daily living 
 within the (ADLs)
level of such as
Pain ability. ambulating,
scale brushing
8/10; his teeth,

gnawing and
pain felt combing
at the at his hair
the right
upper

and lower
quadrant
s of the
abdomen

ASSESSMENT DATA NURSING GOALS AND NURSING INTERVENTIONS EVALUATION

DIAGNOSIS OBJECTIVES AND RATIONALE

Objective: 5. Promote bedrest,

May 24, 2023  allowing client to assume
(Postoperative Day 1) position of comfort
Rationale: Bedrest in low-
Fowler’s position reduces

intra-abdominal pressure;
however, client will naturally
Elevated vital assume the least painful
signs: PR: 121 position.
bpm; RR: 24
cpm 6. Identify and provide
essential adjuncts as
 necessary.
 Rationale: Pillows or blanket
rolls are useful in supporting
extremities, maintaining body
Moaning and alignment, and splinting
crying in pain incisions to reduce muscle
tension and promote comfort

 7. Teach and demonstrate
the use of splinting the
abdomen with pillows
Facial during deep breathing,
grimacing sneezing, coughing or
evident movement.
Rationale: Reduces
 incisional tension, promotes
  maximal lung expansion

Guarding and 8. Provide comfort

protective measures, such as back
behaviors rubs and position changes,
assist with self-care
activities, and encourage
 diversional activities, as
 indicated.
Rationale: May promote
relaxation, redirect attention,
Positioning to
lessen pain (left and reduce analgesic dosage
or frequency.
side-lying
position)
9.Teach and encourage
use of behaviors such as
 guided imagery,
 distractions, visualizations,
and deep breathing
Irritable Rationale: Relaxation
techniques aid in
management of stress,
 promote sense of well-being,
 may reduce analgesic needs,
enhance coping abilities, and
Narrowed focus promote healing.

10. Teach and assist in

 performing range-of-
motion exercises and
May 25, 2023  encourage early
(Postoperative Day 2) ambulation. Avoid
prolonged sitting position.
Rationale: Reduces muscle
 and joint stiffness.
Ambulation returns organs to
Elevated vital normal position and
signs: BP: promotes return to the usual
130/90 mmHg; level of functioning.
PR: 106 bpm;
RR: 26 cpm 11. Schedule care activities
to balance with adequate
 periods of sleep and rest.
Rationale: Rest and sleep

are vital for healing and can
enhance coping with stress
Grimaced face and discomfort.




Guarding and
protective
behaviors




Positioning to
lessen pain (left
side-lying
position)
 


Irritable

May 26, 2023 

(Postoperative Day 3)

Elevated vital
signs: PR: 102
bpm; RR: 23
cpm




Positioning to
lessen pain (left
side-lying
position)




Irritable




Grimace face
when drain
(tube) is moved

ASSESSMENT NURSING GOALS AND NURSING INTERVENTIONS AND EVALUATION

DATA DIAGNOSIS OBJECTIVES RATIONALE
 12. Review and promote client’s
own comfort interventions—
position and physical activity or
inactivity.
Rationale: Successful management of
pain requires client involvement. Use
of effective techniques provides
positive reinforcement, promotes
sense of control, and prepares clients
for interventions to be used after
discharge.

Collaborative:

13. Keep NPO and maintain NG

suction as indicated.
Rationale: Decreases discomfort of
early intestinal peristalsis and gastric
irritation or vomiting.

14. Administer prescribed

analgesics to treat severe pain:

paracetamol 300 mg IV
every 6 hours (6 am-12 nn- 6
pm - 12 mn)




morphine 2 mg IV every 6
hours  (6 am-12 nn- 6 pm -
12 mn)




ketorolac 15 mg IV every 8
hours for 3 cycles ( 4 am, 12
nn, 8 pm)

Priority Problem #2: 

ASSESSMENT NURSING GOALS AND NURSING EVALUATION

DATA DIAGNOSIS OBJECTIVES INTERVENTIO
NS AND
RATIONALE
Subjective: “Dili pa Imbalanced Short-term Goal: Independent: Goals met after 8 hours
siya pakaonon sa nutrition less After 8 hours of 1. Evaluate of nursing interventions,
doctor kay than body nursing interventions, abdomen, as evidenced by:
obserbahan pa siya requirement the patient and SO noting
kung pwede na s related to will: presence and

tanggalon ang NGT medically character of
drain sa iyahang restricted bowel
 patient and SO
ilong og basin mo intake and sounds,
suka pa,” as hypermetab abdominal identified
verbalized by the olic state identify distention, client’s
patient’s mother. individual and reports of individual
(March 24, 2023) nutritional nausea. nutritional
needs. Rationale: needs such as
Gastric need for
distention and adequate
Objective: 
intestinal atony vitamins and
 are frequently minerals,
 present, increased
verbalize resulting in protein and
 Oral understand reduced or caloric intake.
restriction ing of absent bowel
(nothing nutritional sounds. Return 
per orem): needs. of bowel
sounds and 
May 23,
2023 to relief

May 27, patient and SO
 verbalized
2023 2. Note
passage of understanding
plan a diet flatus. of nutritional
 to meet Rationale: needs as
 nutritional Indicates evidenced by
needs and reestablishmen SO saying,
With NGT limit t of bowel “Dapat jud
for gastrointes function. Lack nako bantayan
drainage tinal (GI) of return of iyahang mga
attached disturbanc bowel sounds kinaon, luto-an
es. and function permi og
within 72 hours gulay,
 may indicate maningkamot
  makapalit og
presence of
complications. vitamins para
Mid-upper niya, og
Arm 3. Monitor NG bawalan na
Circumfere Long-term Goal: tube output. nako siya mag
nce After 1 week of nursing Note presence sige og kaon
(MUAC): interventions, the of vomiting og parat og
21 cm patient will: and diarrhea. halang.”
Rationale:
 Large amounts 
 of gastric
 
aspirant, or
initiate severe
Weight- 36 behaviors vomiting and patient and SO
kg , and diarrhea, participated in
Height-163 lifestyle suggest bowel planning a diet
cm , BMI- changes to obstruction, to meet
13.6 kg/m2 regain and requiring nutritional
(underweig to maintain further needs and limit
ht) appropriate evaluation. gastrointestinal
weight (GI)
disturbances
 4. Evaluate
by identifying
 client’s
 foods and
 appetite.
nutrients that
Rationale:
are ideal for
Pale and Appetite may
ingest the patient's
dry skin, nutritionally be suppressed diet.
cracked adequate because of
lips, brittle diet for altered taste,

and dry age, early satiety,
hair activity meal-related
level, and cramping, or
metabolic medications, or After 1 week  of nursing

demands. a combination interventions goals were 
 of these partially met as evidenced
factors. by:

Pale
mucous 
5. Determine 
membrane client’s
s report current
improved nutritional patient’
energy status using exhibited good
 appetite and
level age-
 appropriate consumed full
measurement share of his
 meal when diet
Sluggish s, including
and  weight and was shifted to
fatigued body build, soft diet
demonstrat strength,
e progress activity level, 

in tissue and sleep and
 
healing rest cycles.
free of Rationale:
Poor infection Identifies exhibited 
muscle individual improved
tone nutritional energy level,
 can tolerate
needs and
 provides a walking and
 comparative changing
 demonstrat baseline. positions
e easier
Weight progressiv 6. Monitor
loss of 4 e weight client’s weight 
kg from 36 gain regularly. 
kg (May toward Evaluate
17, 2023) goal and weight in
to 32 kg improve terms of demonstrate
(May 27, MUAC premorbid progress in
2023) weight. tissue healing,
Compare surgical
 incision and
serial weights
  wound
and
anthropometri remained dry
experience c and intact, free
no further measurement of infection
signs of s.
malnutritio Rationale: 
n, with Indicator of 
laboratory nutritional
values needs and
within adequacy of no weight gain;
normal intake. maintained his
range weight of 32
kgs. MUAC
remained at 21
 cm. Note: He
was still on his
first  day of
being on a soft
diet
 

ASSESSMENT NURSING GOALS AND NURSING INTERVENTIONS AND EVALUATION

DATA DIAGNOSIS OBJECTIVES RATIONALE

7. Review client’s nutritional

history, including food
preferences and evaluate
knowledge of nutrition.
Rationale: Identifies deficiencies
and suggests possible
interventions. Helps plan for
individual nutritional  need

8.Teach client and SO  the

importance of well-balanced
meals. Provide information
regarding individual nutritional
needs and ways to meet these
needs within financial
constraints.
Rationale: Providing age-
appropriate guidelines to children
as well as to parents or care
provider may help them in making
healthy choices.

9. Teach client and SO about

nutritionally dense high-calorie,
high-protein, high-vitamin, and
high-mineral foods.
Rationale: Having this information
helps client and SO understand
the importance of a well-balanced
diet.

10. Plan diet with client and SO,

incorporating foods client likes
or food from home. Assist client
in selecting food and fluids that
meet nutritional needs and
restrictions when diet is
resumed.  Limit food(s) that
induce nausea or vomiting or
are poorly tolerated by client.
Rationale: Including client in
planning gives a sense of control
of the environment and may
enhance intake. Fulfilling cravings
for desired food may also improve
intake.
Previous dietary habits may be
unsatisfactory in meeting current
needs for tissue regeneration and
healing.

11. Encourage client to eat high-

calorie, nutrient-rich diet, with
adequate fluid intake.
Encourage use of supplements
 and frequent, smaller meals
spaced throughout the day.
Rationale: Hypermetabolic state
and treatment requires increased
nutrients and fluids to promote
healing and elimination of toxins.
Supplements can play an
important role in maintaining
adequate caloric and protein
intake.

12. Ascertain current financial

status and recent and/or
anticipated changes in
economic status. Explore
related costs of a variety of
foods.
Rationale: Helps in planning for
meeting nutritional needs, such as
purchasing low-cost foods that are
nutritionally rich.

ASSESSMENT NURSING GOALS AND NURSING INTERVENTIONS EVALUATION

DATA DIAGNOSIS OBJECTIVES AND RATIONALE

Collaborative:
13.Refer to nutritionist or
dietitian to develop diet
appropriate to client’s needs
Rationale: Provides assistance in
planning nutritionally sound diet
and identifying nutritional
supplements to meet individual
needs

14. Maintain nothing by mouth

(NPO) status when and
maintain nasogastric (NG)
tube, as indicated.
Rationale: May be needed to
reduce nausea or vomiting.

15. Provide IV fluids as

indicated.
Rationale: Given for general
hydration.

16. Resume or advance diet as

indicated—clear liquids
progressing to bland, low-
residue, and then high-protein,
high-calorie, caffeine-free,
nonspicy, and low-fiber, as
indicated.
Rationale: Allows the intestinal
tract to readjust to the digestive
process. Protein is necessary for
tissue healing integrity. Low bulk
decreases peristaltic response to
meal.