X.

NURSING MANAGEMENT (NURSING CARE PLAN) ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE Independent: EVALUATION

Subjective Cues:

Impaired Comfort/Pain Short term: related to tissue trauma and Usahay sakitan ko sa reflex muscle spasms After 30min. to 1 hour of Will perform baseline samad sa akong ulo. As secondary to surgery nursing intervention, the assessment at the verbalized. client will be able to: beginning of the shift with appropriate pain scale. Clients subjective perception of altered Reassess client every Objective Cues: comfort/pain decreases. 30min. Pain scale of 6 out of 10. BP= 140/90mmHg Grimace noted

After 30min. of nursing intervention, the goals were met. The client was relieved with a pain scale of 4 out of 10.

After 8 hours of nursing intervention, the client verbalized that he was Diminished or absent Show various positions relieved by the medication nonverbal indicators. she may use to reduce pain that was given to him. and discomfort. Long term: Provide relaxing After 8 hours of nursing techniques such as music intervention, the client will therapy. be able to: Dependent: Client will verbalize nonmedication ways of pain Administer medication as relief. prescribed by the physician.

ASSESSMENT DATA

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

Objective Cues: Immobility Destruction in skin integrity Trauma Surgical incision/wound Swelling

Impaired Skin Integrity Short term goal: related to decreased blood and nutrients to tissues After 8 hours of nursing Perform bedside care. interventions, the client will secondary to surgery Inspect skin on daily basis be able to: and observe for changes Participate in prevention and unusualities. measures and treatment Keep the area clean, program. carefully dress wound, Maintain physical well- prevent infection. being. Encourage client to Ability to manage demonstrate good skin situation. hygiene, e.g., wash thoroughly and pat dry Long term goal: carefully after teaching. After 3 days of nursing Dependent: interventions, the client will be able to display timely Administer antibiotics as healing of skin prescribed by the physician. lesions/wounds without complication.

NURSING INTERVENTIONS AND RATIONALE Independent:

EVALUATION

After 8 hours of nursing intervention, goals were met. The client was able to display timely healing of skin lesions/wounds without complication. After 3 days of nursing interventions, goal partially met.

ASSESSMENT DATA

Objective Cues: Weak in appearance Swelling on the surgical site Increase WBC = 14.7103/uL

NURSING INTERVENTIONS AND RATIONALE Risk for Infection related After 8 hours of nursing Independent: to a site for organism intervention, the client Assess for Predictors that invasion secondary to will: increase the risk of infection. surgery Identify the risk factors Reduce the entry of organisms that are present. into the client by meticulous Have partial hand washing, aseptic understanding about technique, and no unnecessary infection control. diagnostic or therapeutic procedures. Clients full knowledge in identifying the risk Instruct individual to ask all factors of the infection. visitors and personnel to wash their hands before approaching Be free from any signs him. and symptoms of related to infection Limit visitors when appropriate. Reduce individuals susceptibility to infection by encouraging and maintaining caloric and protein intake in diet. Dependent: Administer antibiotics prescribed by the physician. as

NURSING DIAGNOSIS

GOALS AND OBJECTIVES

EVALUATION

After 8 hours of nursing intervention, the client was able to meet the goals with an evidence of the absence of the signs and symptoms related to infection.