X.

LIST OF PRIORITY PROBLEM

The first will be Acute pain r/t presence of surgical incision because it falls under physiological need of Maslow’s hierarchy of needs. Second will be Sexual
dysfunction r/t altered body structure as manifested by the presence of surgical incision which falls under love and belonging of Maslow’s hierarchy of needs.
Lastly is Risk for infection related to post operative site because it falls under physiological need of Maslow’s hierarchy of needs.
 Assessment Nursing Rationale Goals and Implementation Rationale Evaluation
Diagnosis Objectives

Subjective: Acute pain r/t Post-surgical pain is a After 4 hours of  Keep at rest in semi-fowlers  Gravity localizes After 4 hours of
“Kumikirot yung presence of complex response to nursing intervention, position. inflammatory exudates nursing intervention,
bandang surgical incision tissue trauma during the client will be into pelvis, relieving the client was able to
inoperahan” as surgery that stimulates able to verbalized abdominal tension, verbalize pain is
hypersensitivity of the relief of pain and which is accentuated reduced from pain
verbalized by the
central nervous system. feel relaxed or at by supine position. scale of 5/10 to 3/10.
client. least the pain is
reduced from pain  Place cold compress on the  Soothes and relieves
Objective: scale of 5/10 to incision site periodically pain through
 Pain scale of 3/10. during initial 24-48 hours as desensitization of
5/10 appropriate. nerve endings.
 Observed
facial grimace  To distract attention
 Instruct in use of relaxation
 Guarding
techniques such as focused and reduce tension.
behavior of the
breathing, imaging, and
incision site
music.
 Positioning to
avoid pain
 Administer analgesics, as  Relief pain facilitates
indicated. cooperation with other
therapeutic regimen.

 Evaluate and document  Ongoing evaluation

client’s response to analgesia. will assist in making
necessary adjustments
for effective pain
management.
 Assessment Nursing Rationale Goals and Implementation Rationale Evaluation
Diagnosis Objectives

Subjective: Sexual dysfunction An individual After 8 hours of  Determine importance of sex  Interpersonal After 8 hours of
“Sabi ng doctor r/t altered body experiences a change in nursing intervention, to individual and client’s problems, lack of trust nursing intervention,
bawal daw ako structure as sexual function due to the client will able motivation of change. and open the client was able to
makipag-sex for 1 manifested by the perceived limitation to discuss concerns communication discuss concerns about
week” as presence of imposed by the surgery. about body image, between partners can body image, sex role,
verbalized by the surgical incision sex role, and contribute to client’s and desirability as a
client. desirability as a concern. sexual partner with
sexual partner with significant other.
Objective: significant other.  Be alert to comments of client  Sexual concerns are
 Inguinal often disguised as
incision site humor, sarcasm, and
 The client is offhand remarks.
sad
 Establish therapeutic nurse-  To facilitate sharing of
client relationship. sensitive information.

 Provide factual information  Provides informed

about individual condition. decision making.

 Provide privacy.  To allow sexual

expression for
individual/partners
without
embarrassment/objecti
on of other.
 Assessment Nursing Rationale Goals and Implementation Rationale Evaluation
Diagnosis Objectives

Objective: Risk for infection Broken skin due to After of 8 hours  Offer mask and tissue to  To limit exposures, thus After 8 hours of
 Incision site on r/t post operative varicocoelectomy will of nursing client/visitors who are reducing cross- nursing intervention,
the right site expose to environment intervention, the coughing/sneezing. contamination. the client will be able
inguinal area. thus there will be an client will be able to demonstrate
increase chance of to demonstrate  Educate proper change of  To practice aseptic techniques, lifestyle
infection on the post techniques, dressing and proper technique and changes to promote
operative site. lifestyle changes disposing of contaminated independency. safe environment.
to promote safe materials.
environment.
 Cover perineal region  To prevent contamination.
dressing with plastic when
using bedpan.
 For mobilization of
 Encourage early respiratory secretions and
ambulation, deep breathing, prevent aspiration.
coughing, & positioning

 Provide regular perineal  Reduces risk of ascending

care. urinary tract infection

 Discuss precautions in  To reduce incidence of

international travel. global infections

 Emphasize necessity of  Premature discontinue of

taking antibiotics.
 Discuss importance of not
taking antibiotics/using
“leftover” drugs unless
specifically instructed by
healthcare provider.
treatment may result in
return of infection &
potential drug resistance.
 Inappropriate use can lead
to development of drug
resistance or secondary
infection.