ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S> “Nahihirapan akong  Risk for ineffective  After 30 minutes of  Position in  To promote lung  After 30 minutes of
huminga”, as verbalized breathing pattern nursing moderate high back expansion nursing
related to decreased interventions: a rest interventions a
O> O2 inhalation via nasal lung expansion normal/ effective normal respiratory
cannula @ 3-4L/min secondary to respiratory pattern  O2 inhalation via  To maintain O2 pattern was
 Complain of chest prolong sedation will be established nasal cannula @ demand established
pain 3-4L/min administer
 With deep shallow
breathing  Closely observed  To have baseline
 V/S as follows: for alteration in vital data and to assess if
BP-120/80mmHg signs there is presence of
RR-24cpm respiratory distress
PR-64bpm
Temp- 37.1C  Auscultate chest  To note any
presence of
abnormal breath
sounds

 Assist in the use of  To promote lung

relaxation expansion
techniques such as
deep breathing
exercises

 Maintained well  To reduce stress

ventilated
environment
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S> “Medyo mahina ako  Risk for altered  After 8 hours of  Encourage  To assess the  After 8 hours of
kumain”, as verbalized nutrition related to nursing verbalization of knowledge of nursing
decreased peristaltic interventions an feelings patient in eating interventions an
O> weight- 48.9 kg movement increased in appetite increased in appetite
 Weak in appearance secondary to present will be observed  Determine ability to  Factors that can was observed, as
 Inadequate food condition chew, swallow and affect evidenced by
intake taste ingestion/digestion verbalization of:
of nutrients “Medyo okay n
akong kumain”.

 Provide diet  To prevent the

modifications such increase production
as: low fat diet, of stones
small frequent
feedings with snack,
and decreased dairy
products

 Encourage to  To stimulate
choose foods that appetite
are appealing

 Provide oral care  To promote comfort

before/after meals
 Promote pleasant,  To reduce stress
relaxing
environment
including
socialization

 Prevent/ minimize  May have negative

unpleasant odor/ effect on appetite
sights

 Promote adequate/  Decreases

timely fluid intake possibility of early
satiety
 ASSESSMENT
S> “Masakit ang tahi ko”,  Severe pain related
as verbalized
O> moaning every time ask
for pain severity
 With facial grimace
 Weak in appearance
 Pain scale: 8/10
DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
 After an hour of  Encourage  To assess the level  After an hour of
to surgical incision nursing verbalization of of pain nursing
done interventions the feelings interventions the
pain will be lessen pain was lessen
from 8/10 to 5/10  Accept client’s  Pain is a subjective from 8/10 to 5/10 as
description of pain experience and evidenced by active
cannot be felt by participation in
others nursing care
rendered
 Observe non-verbal  Observations may
cues such as facial not be congruent
expression with verbal reports
 Monitor vital signs  Usually altered in
pain
 Provide comfort  To alleviate the pain
measures such as
change of position
or backrub
 Encourage use of  To promote lung
relaxation exercises expansion
such as deep
breathing
 Provide quiet  To lessen pain
environment, calm
activities
 Provide non-  To divert the
pharmacologic attention
therapies: listening
radio, reading
books, and
socialization with
others

 Provide adequate  To prevent fatigue

rest periods

 If all of the above  Analgesic can

doesn’t work, lessen the pain
administer
analgesic:
Diclofenac 75mg IV
Q6