NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Knowledge After 1 hour of After 1 hour of
Ano ba ang deficit regarding nursing Review effects of Provides nursing
gagawin sakin? condition, interventions, the surgical procedure knowledge base interventions, the
as verbalized. prognosis, patient will identify and future from which patient patient was able to
treatment, self relationship of expectations. can make identify
Objective: care, and signs and informed choices. relationship of
discharge symptoms related signs and
Confusion needs related to to surgical Discuss resumption Client can expect symptoms related
Request for unfamiliarity procedure and of activity. to feel tired when to surgical
information. with information actions to deal Encourage light she goes home procedure and
Fear resources. with them. activities initially, and needs to plan actions to deal
with frequent rest a gradual with them.
periods and resumption of
increasing activities activities.
or exercise as
tolerated

Identify individual Strenuous activity

restriction like intensifies fatigue
avoiding heavy and may delay
lifting and healing.
strenuous activities.

Identify dietary Facilitates healing

needs like high or tissue
protein and regeneration and
additional iron. helps anemia if
present.
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Review incisional Facilitate

care when competent self-
appropriate. care, promoting
independence.

Stress the Provides

importance of opportunity to ask
follow up care questions, clear up
misunderstandings
, and detect
developing
complications.

Identify sign and Early recognition

symptoms requiring and treatment of
medical evaluation. developing
complications such
as infection or
hemorrhage may
prevent life
threatening
situations.
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Assessment

Subjective: Acute pain After 30 minutes Independent: Subjective:
Masakit ang related to post- of nursing Masakit ang
aking tahi, as surgical incision intervention, pain - Establish rapport. -To have a good aking tahi, as
verbalized. site intensity will nurse-client verbalized.
decrease from relationship
Objective: 8/10 to 4/10. Objective:
-pain scale of - Monitor vital signs. -To establish a -pain scale of
8/10 baseline data 8/10
-with guarding -with guarding
behavior - Assess quality, -To establish baseline behavior
-with facial characteristics, data for comparison in -with facial
grimace severity of pain. making evaluation grimace
-irritable and to assess for -irritable
-with foley possible internal -with foley
catheter intact bleeding. catheter intact
draining to draining to
yellowish urine - Provide comfortable -Calm environment yellowish urine
output environment helps to decrease the output
changed bed linens anxiety of the patient
and turned on the and promote
fan. likelihood of
decreasing pain.
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- Instruct to put pillow on - To protect the area

the abdomen when of the incision to
coughing or moving. improve comfort. And
to initiate nonstressful
muscle-setting
techniques and
progress as tolerated,
based on the degree
of separation.
- Instruct patient to do
deep breathing and - For pulmonary
coughing exercise. ventilation, especially
when exercising, and
to relieve stress and
promote relaxation.
- Provide diversionary
activities. Initiate - To promote
ankle pumping, circulation, prevent
active lower venous stasis;
extremity ROM, and prevent pressure on
walking the operative site.

Collaborative:
- Administer Celecoxib
200 mg 1 cap for -To provide chemical
pain three times a effect and therapeutic
day effect
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired After 8 hours of INDEPENDENT: After 8 of
physical mobility rendering nursing rendering nursing
hindi ako related to post- intervention, the 1. Assist with 1. Until healing care, the goal was
masyadong op pain patient will be activity/progressive occurs, activity is met as evidenced
gumagalaw kasi able to: ambulation. limited and by movement
masakit yung advanced slowly within range of
operasyon ko as Increase according to motion.
verbalized strength and individual tolerance.
function of 2. Encourag
Objective data: affected body e and facilitate early 2. The longer the
part ambulation and other patient remains
Limited ADLs when possible. immobile the greater
range of Move within Assist with each the level of
motion range of initial change: debilitation that will
Slowed motion dangling, sitting in occur.
movement chair, ambulation.
Reluctance
to attempt 3. Provide patient with
movement ample time to perform 3. To promote
mobility related task. optimal level of
function.
DEPENDENT:

1. Administer DEPENDENT:
analgesic medication:
Ketorolac IVTT x 4 1. To relieve mild or
doses q 8 hours as moderate pain.
prescribe by the
physician.
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Activity After one hour of Establish Rapport To gain clients After one hour of
ang hirap intolerance nursing participation and nursing
kumilos dahil sa related to chest intervention, cooperation in the intervention,
tubo as tube patient will use nurse patient patient was able
verbalized thoracostomy identified interaction to use identified
techniques to techniques to
Objective: improve activity Monitor and record To obtain baseline improve activity
Generaliz intolerance. Vital Signs data intolerance.
ed weakness Assess patients To note for any
Verbalizati general condition abnormalities and
on of lack of deformities present
within the body
energy
Inability to Adjust clients daily To prevent strain and
perform activities and reduce overexertion
intensity of level.
activities of
daily living Discontinue activities To conserve energy
that cause undesired and promote safety
psychological changes

Instruct client in To relax the body

unfamiliar activities
and in alternate ways
of conserve energy

Encourage patient to To provide relaxation

have adequate bed
rest and sleep
NURSING CARE PLAN

Provide the patient To prevent risk for

with a calm and quiet falls that could lead to
environment injury

Assist the client in Fatigue affects both

ambulation the clients actual and
perceived ability to
participate in activities

Note presence of To determine current

factors that could status and needs
contribute to fatigue associated with
participation in
needed or desired
activities

Ascertain clients ability To sustain motivation

to stand and move of client
about and degree of
assistance needed or
use of equipment

Give client information To enhance sense of

that provides evidence well being
of daily or weekly
progress

Encourage the client to To promote easy

maintain a positive breathing
attitude
NURSING CARE PLAN

Assist the client in a To maintain an open

semi-fowlers position airway

Elevate the head of the To prevent injuries

bed

Assist the client in To avoid risk for falls

learning and
demonstrating
appropriate safety
measures

Instruct the significant To help minimize

others not to leave the frustration and
client unattended rechannel energy

Provide client with a To indicate need to

positive atmosphere alter activity level