DATE AND TIME FOCUS /PROBLEM NURSING A CTION EVALUATION SIGNATURE

1 Acute Pain related D:Patient has pain on .........site Patient

to surgical related to ..................................... verbalises
incision,tissue P:Reduce severity of pain,patient reduction in
damage,medical displays improved well being severity of
conditions,diagnostic A:Assess the pain location of pain, pain,pain score
procedures (Pain severity,quality,duration and
score) precipitating factors,assess the signs
and symptoms of pain including high
Bp,pulse rate,temparature and colour
change of skin,get rid of additional
stress factors of pain,provide
comfortable position,rest periods and
non pharmacological
methods,pharmacological methods as
per physicians order.
2 Imbalanced nutrition D:Poor nutritional status related to Patients
less than body less food intake. nutritional
requirement related P:To improve the nutritional status of status is
to post anaesthesia the patient. improving
effect as evidenced A:Assessment of nutritional
by decreased status,Assessing signs of nausea or
peristaltic motility vomiting,administration of iv fluids
and less food intake as per order,encouraging food and
fluid intake,maintain intake output
chart for monitoring fluid balance of
body.Providing less gastric irritating
and easy digestible soft foods
initially.

3 Impared physical D;Patients movements are resricted Patient feels

mobility related to P;Performs physical actvity comfortable and
surgical procedure as independently or within limit coping with
evidenced by A.Assessment of Range of motion of limitations.
restricted movements patients extrimities,Provided
of extremities assisstive devices for tolileting
needs,encouraged active exercises of
extremities,change in position.Set up
bowel program by providing
laxatives ,stool softners as per doctors
order.Offer divertional therapy
4 Risk for fall related D;Patient is at risk for fall,due to age Patient is on
to age and disease and disease condition,fall risk score.. safe
condition as P;Patient will be free form injury environment
evidenced by fall A;Placed the patient near by nurses and fall risk
risk score... station for close observation,Keep the reduced to
belongings of the patient at reachable some extend
distance,prevent the patient from
going out of bed without any
assistance. Proper orientation to
 room/ward,adequate lighting
provided,nonskid footwares
adviced.Side rails are up when patient
is on bed,fall risk alert sign boards
hanged at iv stand.Adviced to use
grab bars in bathroom.
Risk for infection D;Patient is at risk for infection Patient is free
5 related to surgical related to surgical incision from infection
incision P;Prevent risk for infection to some extend
A;Assess and moniter nutritional
status and weight,Assess the surgical
site for signs of
redness,swelling,purulent
discharges,pain,increased
temparature.Maintain proper
handwashing and aseptic techniques
before every procedure.Assessment
insertion sites of
drains,tubes,catheters etc. For signs
of infection,watch for
hyperthermia.Administered
antibiotics as per order.Removal of iv
cannula after 72hours,urinary catheter
after 48hours of surgery to prevent
pivc infections and CAUTI.
`6 Risk for impared D;Patient is confined to bed for Patients skin is
skin integrity related several hours,and less movements of intact
to extremities
malnutrition,prolong P;Maintain normal skin integrity
ed bedrest A;Assess the skin for any signs of
redness,skin peel etc.Provide position
change every second hourly and back
care second hourly.If patient at high
risk provide airbed,mattress.Apply 5
pillow method for protecting the
pressure points from risk for pressure
sore.
7 Ineffective breathing D:Patient has nasal packing on bi/uni Patient is
pattern related to lateral nose comfortable and
nasal surgery as P:Patient 's oxygen saturation will be spo2 is
evidenced by maintained at normal level maintaining
presence of nasal A:Assess the general condition of the
packig patient , Monitoring of spo2
frequently,provide reassuarance and
provide semifowlers position for easy
breathing,saline or oxy drops
administer as per doctors order,advice
patient to take mouth breathing.Also
advice patient not to sneeze,blow
strongly,and light nasal bleeding is
suspected.
8 Ineffective health D:Patient has uncontrolled blood Patients sugar
maintance related sugar levels. level is
to demonstration P:Patientts blood sugar level maitain maintaining
of uncontrolled within normal limit. within normal
diabetes and A: Demonstrate how to take his limit
reporting lack of blood sugar and interpret the
education about results.
diabetes as Demonstrate how to give himself
evidence by high insulin injections using the sliding
blood sugar and scale. Verbalize how often and
knowledge when he needs to check his blood
deficient about sugar.The nurse will consult with
controlled the dietitian to educate the
diabetes. patient on diet regime for
diabetics.

9 Deficient knowledge D:Patient has knowledge deficit Patient is Ee

regarding disease regarding treatment,disease process receptive and
condition,treatment and individual needs. attendive
and individual P:Patient will participate in learning
needs(diabetes) process
A:Determine the clients readiness for
learning,Identify client’s support
person that may also need
information about the planned
diabetes regimen. Use short and
simple concepts. Summarize as
needed.Provide positive
reinforcement.

10 D:Patient has unstable blood sugar Patients sugar

Risk for unstable levels level is
blood sugar level P:Patient will maintain normal blood maintaining
related to poor sugar level within the
diabetic control A:Assess the blood sugar levels pre normal limit
and post meals and recorded.,Identify
the factors affecting unstable blood
glucose levels,Determine the factors
affecting dietary practices of the
client,Refer the client to a dieticin to
plan the dietary needs,advice the
patient to avoid stressful situations
that trigger the condition.