VII.

NURSING MANAGEMENT

A. NURSING CARE PLAN

CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

S – “Ano bang Anxiety related Due to the fear of After 1˚ of • Established • To gain trust. After 1˚ of
gagawin sakin sa to insufficient the unknown or implementing rapport. implementing
loob? Masakit knowledge anxiety, and due to nursing care, nursing care, pt’s
ba?” regarding the the knowledge patient’s • Discuss to pt. the • Knowing the anxiety decreased.
surgical deficit to the anxiety will operative procedure
O– procedure. operative decrease. procedure that he itself, pt. will
Worried procedure, pt. will be undergone. be calm.
Irritable become irritable
Changed in PR and worried. • Spend time talking • Allowing pt.
Increased in with the pt, allow to express his
perspiration / to express feelings, it
sweating. feelings. will lessen
the fear.
With the V/S of: • Adjust
T – 37.1 ˚C environment to • Giving
P – 90 bpm promote pt. comfort to pt,
R – 20 Bpm comfort. pt. will lessen
BP – 130/80 the anxiety.
mmHg
 CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS EXPLANATION

S–ø Acute Pain Because of incision After 1˚ of • Established • To gain trust. After 1˚ of
O– related to Post or operation done, implementing rapport. implementing
Observed with operative patient’s pain nursing care, nursing care, pt’s
guarding behavior procedure. receptors activated patient will be • Instructed pt. to • Prevents pain decreases from
upon palpation to from that, it will able to : avoid positions pressure to the 7 to 5.
the wound. end up to brain and verbalize that increase incision that
it will be decrease pain pressure to the causes pain.
Observed recognized by the from pain scale wound.
positioning to body and will feel of 7 to 5 or
avoid pain on pain. below. • Instructed to clean • Proper
incision site. the wound cleaning of
properly and wound will
(+) facial grimace aseptically. prevent
upon palpation on infection.
the wound.
• Instructed to take • Proper taking
With the pain scale meds like pain of prn meds
of 7 from 10. reliever as will help to
prescribed in decrease
With the V/S of: proper dosage pain.
T – 36.9 ˚C
P – 84 bpm
R – 19 Bpm
BP – 120/80
mmHg
CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
S – “Hindi pa ako Activity Due to the surgical After 1-2˚ of • Established • To gain trust. After implementing
makagalaw dahil intolerance procedure done, pt. implementing rapport. nursing care, pt. and
sa operasyon” related to post cannot move alone, nursing care, pt. • Involve both pt. • The health S.O will gain
operative he has a limited and S.O will be and S.O in care provider knowledge
O– procedures. motion. able to gain implementing will have an regarding proper
Observed with knowledge nursing care. easy task assisting and
limited regarding the importance of pt’s
movements. importance of • Discussed to S.O • Prevent condition.
proper assisting the proper pressure to
With the V/S of: to pt. assisting during the wound
T – 36.8 ˚C sitting, lying and site
P – 79 bpm ambulating
R – 19 Bpm
• Discussed the • Hygiene will
importance of prevent
hygiene. infection.

• Discussed the • Proper

importance of wound
proper nutrition. dressing will
prevent
infections

• Proper
nutrition will
help fast
wound
healing.

CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

 DIAGNOSIS EXPLANATION

S–O Risk for fluid Due to decreased Short Term: • Weigh patient • Provides Short Term:
volume deficit secretion of bile and accurately information
O – patient r/t vomiting. there is obstruction After 6 hours of After 6 hours of
assess about fluid
manifested:: on the gall bladder, nursing nursing
skin/mucous status/
there is also intervention and intervention and
- increased RR decreased membrane, circulating
interaction, the interaction, the
absorption of fat peripheral and
- poor skin turgor patient will patient shall have
which causes pulses and replacement
vomiting. verbalize verbalized
capillary needs.
- increased body Excessive vomiting understanding understanding and
refill.
temperature can lead to fluid and demonstrate demonstrated
and electrolyte techniques in • Review techniques in
- weakness loss/imbalance. • For baseline
maintaining laboratory maintaining
adequate studies (Hgb, data. adequate
hydration AEB Hct, hydration AEB
pt. may manifest: normal skin electrolytes, normal skin
turgor, moist ABG, clotting turgor, moist oral
-dry skin and
oral mucous times). mucous
mucus membrane
membrane. membrane.
-change in mental • Monitor for
• Prolonged
status s/sx of
vomiting,
increased/
Long Term: gastric Long Term:
- hypoactive or continued
depressed bowel aspiration
After 3 days of nausea and After 3 days of
sounds and
NI, patient will vomiting, nursing
restricted intervention,
be able to abdominal
-loss of fluid oral intake patient shall have
maintain cramps,
through abnormal can lead to maintained
adequate fluid weakness,
route deficits in adequate fluid
volume balance irregular PR, volume balance
 and hydration hypotension Na, K and and hydration
AEB normal and increased Cl. AEB normal skin
skin turgor, body turgor, moist oral
mucous
moist oral temperature
membrane.
mucous • Decreases
membrane. • Perform
frequent oral dryness of
hygiene with membranes;
alcohol-free reduces.
mouthwash,
apply
lubricants.

• Keep NPO as • Decrease GI

ordered. motility.

• Administer IV • Identifies
fluids, deficit and
electrolytes, aids in
as ordered. intervention
for
replacement
of loss
fluids and
maintains
circulating
volume.

CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

 DIAGNOSIS EXPLANATION

Impaired skin The integumentary Short Term: • Establish • To gain Short Term:
S–O integrity r/t system is the largest rapport with their trust
break in the multifunctional After 4 hours of After 4 hours of
the patients. and
O – patient skin due to organ of the body. nursing nursing
cooperation.
manifested: surgical incision He has impaired intervention, intervention,
in the RUQ. skin integrity patient’s will be • To note for patient’s SO was
- surgical wound because of the • Assess patient
able to s/sx. able to participate
on RUQ breakage in the general
continuity in the participate in in prevention
- itchiness prevention condition. measures and
skin.
measures and • Monitor vital • Serve as a treatment
- (+) skin rashes treatment program.
sign baseline
- (+) erythema program. data.

- disruption of the
skin surface • Note changes
Long Term: • For baseline
in skin color, Long Term:
- jaundice After 2 day of texture, and comparison
nursing turgor After 2 day of
intervention, nursing
patient will be • Inspect intervention,
pt. may manifest: • To patient is free
free from surrounding
document from erythema
-invasion of body erythema and skin for
maintain status/provi and maintain
structure erythema optimal
optimal de visual
nutrition/physic baseline for nutrition/physical
-destruction of
al well being comparison. well being.
skin layer

• to arrest
• Keep the area body’s
clean and dry. natural
process
repair

• moisture
• Limit use of potentates
plastic skin
material. breakdown

• to determine
effectivenes
• Due s.
medications
given.
 CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS EXPLANATION

Short Term: • Assess • To obtain Short Term:

S–Ø Risk for spread The skin is the first underlying comparative
of infection r/t line of defense After 4 hours of After 4 hours of
condition and baseline
O – patient break of skin. against infection. nursing nursing
body data
manifested: Any break in its intervention, the intervention, the
continuity will temperature.
patient will • To note for patient shall have
- hyperthermia allow
verbalize • Monitor and progress and verbalized
microorganisms to
- redness at enter the body, understanding recorded vital evaluate for understanding of
insertion site which in turn can of health signs. risk of health teachings
cause infection. teachings infection. provided to
- swelling provided to prevent spread of
prevent spread • It supports infection.
Patient may • Encourage
of infection. circulating
manifest: increase fluid volume and
intake if not tissue
- Increase in WBC Long term:
contraindicate perfusion.
- open wound Long Term: d.
After 2 days of
After 2 days of Nursing
Nursing • Reduces Intervention the
pt. may manifest: Intervention, • Promote metabolic pt. shall exhibit
the pt. will adequate rest demands or decrease risk of
- inadequate exhibit decrease periods
risk for spread oxygen spread of
acquired immunity
of infection. • Encourage infection.
• To decrease
- malnutrition proper further
hygiene. complicatio
- trauma
n.
 • To prevent
spread of
• Perform infection.
aseptic
technique.