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NURSING DX NURSING INTERVENTIONS RATIONALE
1.Ê Acute pain r/t Independent: Independent:
tissue trauma a.Ê Encourage verbalization of feelings a)Êto evaluate coping abilities and
about the pain to identify areas of additional
concern

b)ÊTo promote non


b.Ê Provide comfort measures such as
pharmacological pain
touch, nurseǯs presence, quiet
management.
environment and calm activities.
c)Ê To distract attention and
c.Ê Encourage use of relaxation
reduce tension.
techniques such as focused breathing,
guided imagery.
d)Êto assist client to explore
d.Ê Encourage diversional activities such
methods for
as watching TV, listening to radio and
alleviation/control of pain
socialization to others
Dependent:
Dependent:
a)Êfor management of severe and
a)ÊAdministration of narcotic analgesic
persistent pain
u.Ê Impaired Independent Independent
physical a.Ê Instruct the patient to use overhead a.Ê For position changes
mobility r/t trapeze
musculoskeletal
impairment b.Ê Instruct patient or SO to maintain b.Ê To prevent hip dislocation
from surgery correct position and therapeutic hip
precaution at all times in bed and
while ambulating.

c.Ê Support affected body parts using c.Ê To maintain position of


pillow function and reduce risk of
pressure ulcers.

d.Ê Encourage participation of self-care d.Ê Enhances self-concept and


and recreational activities sense of independence

e.Ê Encourage to perform passive ROM e.Ê To promote circulation


exercise

f.Ê Encourage adequate intake of fluids f.Ê Promotes well-being and


and nutritious foods. maximizes energy
production.
3.Ê Ineffective Independent Independent
tissue a.Ê Encourage early ambulation. a.Ê Enhances venous return
perfusion r/t
prolonged b.Ê Apply antithromboembolic b.Ê To prevent venous stasis
immobility hose/compression bandages to lower
extremities.

c.Ê Encourage smoking cessation. c.Ê Smoking cause


vasoconstriction and may
further compromise
perfusion

d.Ê Discourage massaging calf in presence d.Ê To prevent embolization.


of varicose veins.

Dependent Dependent
a.Ê Administration of Heparin via IV a.Ê As a prophylactic measure
against thrombophlebitis.












.Ê Activity Independent: Independent
Intolerance a.Ê Adjust activities a.Ê To prevent overexertion
r/t
musculoskel b.Ê Provide positive atmosphere, while b.Ê Helps minimize frustration
etal acknowledging difficulty of the and rechannel energy.
impairment situation for the client.
from surgery
c.Ê Promote comfort measures and c.Ê Enhance ability to
provide for relief of pain. participate in activities

d.Ê Assist client learning and d.Ê To prevent injuries


demonstrating appropriate safety
measures

e.Ê Encourage client to maintain positive e.Ê To enhance sense of well


attitude. being

f.Ê Plan care to carefully balance rest f.Ê To reduce fatigue.


periods with activities.
D.Ê Risk for Independent Independent
infection r/t a.Ê Stress proper hand hygiene a.Ê A first line of defense against
surgical infection
incision
b.Ê Cleanse incision per facility protocol b.Ê To reduce potential
with appropriate solution. infections

c.Ê Change surgical wound dressings. c.Ê To reduce potential


infections

d.Ê Cover pelvic region dressings cast d.Ê To prevent contamination.


with plastic using bedpan.

e.Ê Maintain adequate hydration and e.Ê To avoid bladder distention.


catherization.

f.Ê Provide regular urinary f.Ê Reduces risk of ascending


catheter/perineal care. urinary tract infection.

Dependent Dependent
a.Ê Administer antibiotic as ordered. a.Ê For prophylactic purposes
Ê