ASSESSMENT

DIAGNOSIS

BACKGROUND KNOWLEDGE

ACUTE PAIN PLANNING

INTERVENTION Independent:

RATIONALE

EVALUATION

S- Masakit yung Inoperahan sakin, as verbalized by the client. O -presence of surgical incision on left plantar area f foot - facial grimacing when touched on affected body part - guarding behavior such as trying to protect affected body part when nurse tries to reach for it - pain on the left foot (pain scale of 7/10)

Acute pain related to post surgical procedure as evidenced by pain scale of 7/10.

Long term goal: Tissue trauma from After 2-6 hours of post surgical Nursing Intervention procedure will trigger the client will be able the release of to demonstrate proper neurotransmitter. This management to pain will stimulate pain with use of relaxation receptor called techniques and nocireceptor that is diversional activities. sensitive to noxious stimulus that carries pain impulses. Then the peripheral nerve fibers from synapses Short term goal: will carry impulse to the spinal cord going After 30-45minutes of to the brain. It will nursing intervention, ascend to reticular the client will be able activating system, to express reduction limbric system, of pain from 7/10 to thalamus, 4/10. hypothalamus, medulla and cerebral cortex. Then the brain perceives and interprets the pain.

1.Identify reports of pain, location, duration and intensity.

2.Discuss normality of foot sensation.

1.To provide direction for pain treatment plan and aids in identifying degree if discomfort and need for effectiveness of analgesia.

2. To provide in assurance that sensations are not imaginary and affects the clients ability to relax 3.Provide basic comfort effectively. measures. 3.To promote relaxation. 4. Encourage diversional activities like watching television 4. To help refocus and talking to others. attention from pain.

Long term goal: Goal met. After 2-6 hours of Nursing Intervention the client was able to demonstrate proper management to pain with use of relaxation techniques and diversional activities.

Short term goal: Goal met. After 3045minutes of nursing intervention, the client was able to express reduction of pain from 7/10 to 4/10.

5.Teach client deep breathing exercise.

Dependent:

5.To promote patent airway.

1. Administer analgesics as ordered

To provide relief and discomfort of pain.

ASSESSMENT

DIAGNOSIS

IMPAIRED PHYSICAL MOBILITY BACKGROUND PLANNING INTERVENTION KNOWLEDGE Long term goal: After 1-2 days of Nursing Intervention the client will be able to maintain optimal musculoskeletal functioning as evidenced by gradual return of normal ROM. Independent: 1. Instruct client and monitor active ROM exercise at least twice daily.

RATIONALE

EVALUATION

S- Hindi ko pa maigalaw ang paa ko. O- Limited range of movement -reluctance to attempt movement -difficulty in walking and standing -slowed movement -decreased muscle

Impaired physical mobility related to neuromuscular impairments as evidenced by reluctance to attempt movement.

Related to post surgical procedure, it will result to alteration in the functions of movement. There would be limited ROM and decrease muscle mass and strength so the patient has a reluctance to attempt movement.

2. Encourage client to participate

1. Active ROM exercises maintain joint mobility and muscle tone and improve cardiovascul ar function. 2. Performing self-care activities

Long term goal: After 1-2 days of Nursing Intervention the client will be able to maintain optimal musculoskeletal functioning as evidenced by gradual return of normal ROM.

strength/mass

Short term goal: After 2-4 hours of nursing intervention, the client will be able to demonstrate techniques that enables resumption of activities and increases activity tolerance to desired level.

actively in selfcare activities as much as possible.

3. Encourage optimal ambulation within physical limitations 4. Instruct client in correct use of assistive devices.

uses joints and muscles helping maintain their function. 3. Ambulation encourages good blood circulation. 4. Facilitates mobility without injury to the body. 5. Provide clients safety.

Short term goal: After 2-4 hours of nursing intervention, the client will be able to demonstrate techniques that enables resumption of activities and increases activity tolerance to desired level.

5. Inform client on safety precautions when moving or transferring from one place to another. 6. Provide positive reinforcement during activities.

6. Provides incentive to become independent as possible. 1. Provides analgesic effects for

Dependent: 1. Administer

analgesics as prescribed.

better activity tolerance.

ASSESSMENT

DIAGNOSIS

IMPAIRED SKIN INTEGRITY BACKGROUND PLANNING INTERVENTION KNOWLEDGE Long term goal: Independent:

RATIONALE

EVALUATION

S- Masakit yung Impaired skin integrity inoperahan sa akin related to surgical removal of skin and O- Disruption of tissue as evidenced by skin layer the presence of incision subcutaneous site. tissues -presence of incision site -pain scale of 7/10 - With dry and intact dressing at the left foot.

The presence of incision from the recent surgery alters the normal functioning of the skin and its layers. The disruption irritates nerve endings and causes release of norireceptors that induces pain sensation. This then marks the alteration of the integrity of the integumentary system of the body.

Long term goal: After 1-2 days of nursing intervention the client will be able to demonstrate optimal self-care to prevent complications upon restoration of skin integrity. Short term goal: After 1-2 hours of nursing intervention the client will be able to demonstrate behaviors and techniques to promote healing and prevent complications from wound. 1. Keep the skin clean and dry; lubricate if necessary. 1. To make the skin less vulnerable to breaking down due to dryness. 2. This is to promote feeling and decrease pain sensation 3. Changing position promotes blood circulation and thus Goal met. After 1-2 days of nursing intervention the client was able to demonstrate optimal self-care to prevent complications upon restoration of skin integrity. Short term goal: Goal met. After 1-2 hours of nursing intervention the client was able to demonstrate behaviors and techniques to promote healing and

2. Provide appropriate protective and pressure relieving devices and measures. 3. Establish a repositioning schedule.

promote progressive healing. 4. Ensure adequate nutritional and fluid intake 4. Promotes progressive healing of wound. 5. Muscle contractions stimulate circulation of blood to the skin. 1.To treat possible specific infection and enhances healing.

prevent complications from wound.

5. Encourage client to do active ROM exercises every 2-3 hours.

Dependent: 1.Administer antibiotics as ordered.