Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Subjective Data: Acute pain Goal: Provide accurate, Being informed Goal Met:
Pain score of 10 in a related to After series off honest about the After series off
scale of 1 – 10 with 10 distention of nursing information to progress of the nursing
being the highest intestinal intervention, the patient/SO situation provides intervention, the
tissues by patient will be able emotional patient verbalized a
Objective Data: inflammation to verbalize relief of support, helping relief of pain as
as evidenced pain. to evidenced by
Guarding by patient’s decrease anxiety decreased guarding
behavior pain score of Assess pain, Useful in behavior.
Rebound 10 out of 10. noting location, monitoring
tenderness characteristics, effectiveness of
V/S taken as and severity. nursing
follows: Investigate and intervention and
- T: 37.9 c report changes the progression of
- HR: 110bpm in pain as the condition.
- RR: 21cpm appropriate
- BP: 130/80 Keep at rest in Gravity localizes
semi-Fowler’s inflammatory
position exudate into the
lower abdomen
or pelvis, relieving
abdominal
tension, which is
accentuated by
supine position
Place ice bag on Soothes and
abdomen relieves pain
periodically as through
appropriate desensitization of
nerve endings.
Note: Do not use
heat, because it
may cause tissue
congestion
Maintain NPO Keep patient NPO
status until symptoms
subside and/or
surgery is ruled
out.
Administer Relief of pain
analgesics as facilitates
indicated. cooperation with
other therapeutic
interventions
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Objective Data: Risk for Goal: Determine client’s To clarify Goal Met:
Dressing on surgical infection The client will level of discomfort intervention needs After series of
site related to develop and and priorities nursing
incision/suture maintain Perform routine skin Inspection can intervention, the
in the right optimal inspections, assessing identify developing client developed
lower condition for color, temperature, problems and and maintained
abdomen wound healing, surface changes, and promotes early optimal condition
free of infection texture of surgical intervention, thus for wound healing
site reducing likelihood as evidenced by
of acquiring the display of
infection. timely healing of
Keep surgical area Prevents infection, surgical incision
clean and dry; Use protect wound and without infection
appropriate dressing surrounding tissues and other
barriers, wound from excoriating complications.
coverings, drainage secretions/drainage
appliances and skin- while assisting
protective agents for body’s natural
draining wounds. process of repair
Periodically observe To determine the
skin condition for progress of wound
possible healing.
complications
Practice and Reduce risk of
emphasize constant infection and other
and proper hand HAIs
hygiene by all
caregivers between
therapies and clients.
Instruct the
client/significant
others/visitors to
wash hands as
indicated.
Determine The situation can
psychological effects be devastating for
of condition on client’s self-image
client; provide and self-esteem.
emotional and
psychological
support.
Refer to a dietitian To optimize healing
for adequate potential
nutritional and fluid
intake.
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Objective: Deficient Goal: Determine the The patient may Goal Met:
Patient have chills, knowledge After series of client’s ability, not be physically, After series of
muscle rigidity and related to lack nursing readiness, and emotionally, or nursing
groaning. of information interventions, the barriers to learning mentally ready interventions, the
as evidenced patient will Identify symptoms Prompt patient
Vital signs were as by become more requiring medical intervention verbalized
follows: development knowledgeable evaluation (increasing reduces risk of understanding of
BP: 130/90mmHg of preventable regarding his pain; erythema of serious disease process
HR: 130bpm complications present wound; presence of complications and potential
RR: 23 cpm condition. drainage, fever). (delayed wound complications as
Temp: 40 c healing) evidenced by
Review postoperative Provides patient’s
activity restrictions information for participation in
patient to plan for learning process
return to usual
routines without
untoward
incidents.
Discuss care of Understanding
incision, including promotes
dressing changes, cooperation with
bathing restrictions, therapeutic
and return to regimen,
physician for suture enhancing healing
and staple removal. and recovery
process.
Provide information To prevent
relevant only to the information
patient’s situation overload and
better
understanding
Provide an To facilitate
environment that is effective and
conducive to learning efficient learning
Use short simple
sentences and
concepts Repeat and
summarize as needed
Use gestures and
facial expressions
that help convey
meaningful
information
Provide for feedback
and evaluation of
learning
