Nursing Diagnosis Expected Outcomes Implementation Evaluation

 Pain related to  Patient well verbalize pain  Have the patient splint the incision  Patient now in
general condition
surgical procedure decreased from 6 to 3 on pain site with hand or pillow when free from
as manifested by scale. coughing to lessen pain and protect verbalization of
patient pain and he said the
site from increased intraabdominal scale of pain now is
verbalization. pressure. Splinting and proper 3 from 10.
 Patient will be able to do daily positing reduce the stress on the
activity without Assistance incision area.  Patient now do
activity with less
assistance.

 Keep bedding clean, dry, and free  Patient have good

 Patient will be free from information about
of wrinkles and debris.
impairment skin integrity disease and wound
care.

 Patient will have good  Provide therapeutic environment—  No signs or

proper temperature and humidity, symptoms of
knowledge about disease and infection on patient
about wound care ventilation, visitors. or around surgical
incision during my
shift
 Patient will be free from sign  Put patient in comfort position to
and symptom of infection decrease pressure on surgical
during my shift incision.
 Explaining pain relief methods, such as
Breathing exercises, heat application, and
progressive relaxation because Breathing
exercises and relaxation techniques
decrease oxygen consumption, respiratory
rate, heart rate, and muscle tension, which
interrupt the cycle of pain, anxiety, &
muscle tension.

 Encourage progress in the client activity

level during my shift by:

I. Allow the client legs to dangle first;

support him from the side because
Dangling the legs helps minimize
orthostatic hypotension.
II. Increase the client time out of bed by 15
minutes each time
III. Allow him to set a comfortable rate of
ambulation, to prevent overexertion.
IV. Encourage the client to increase activity
when pain is at a minimum or after pain
relief measures take effect.
 Perform hand washing before and after
contact with patient to prevent
contamination.

 Inspect dressings routinely and change it if

necessary.

 Record amount and type of wound

drainage.

 Turn the patient frequently and maintain

good body alignment.

 Teach patient how to care wound and how

to promote healing

 Check dressing for drainage and incision

for redness and swelling.

 Monitor for other signs/symptoms of

infection: fever, chills, malaise,
diaphoresis.