ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Data; Knowledge deficit After an hour of INDEPENDENT: GOAL MET

The patient stated regarding illness, nursing
“Dakkil gayam ti treatment, self intervention, the - Review with - Validates current level - Patient was able to
sugat ko ah.” care, and patient will: patient/SO of understanding, demonstrate procedure
discharge needs understanding of identifies learning correctly and explain
Patient also stated related Short Term Goal specific diagnosis, needs, and provides reasons for the action
“Anya ngay ikasta unfamiliarity with - Patient will treatment alternatives, knowledge base from
mi ta pupmaspas information as understand her and future which patient can make - Express correct
nga umbimbag evidenced by condition/disease expectations. informed decisions. information regarding
diyay sugat ko.” question and process and treatment the illness/condition.
request for - Aids in
information - Patient will exhibit an identification of ideas,
Objective data: understanding of how - Determine patient's attitudes, fears,
- The patient has proper self-care should perception of cancer misconceptions, and
no history of either be and cancer gaps in knowledge
minor or major treatment(s); ask about about breast cancer.
surgeries. - Patient will verbalize patient's own/ previous
- Different understanding and experience or
perception on the participate in experience with other
surgical procedure therapeutic actions. people who have (or - Helps with adjustment
had) cancer. to the diagnosis of
cancer by providing
After 2days of - Provide clear, needed information
nursing intervention accurate along with time to
will: information in a factual absorb it.
but sensitive manner. Note: Rate and method
Long Term Goal Answer questions of giving information
- Patient will specifically, but do not may need to be altered
understanding the bombard with to decrease patient's
discharge health unessential details. anxiety and enhance
teaching such as the ability to assimilate
importance of follow- information
up check up.
- Patient has the
"right to know" (be
- Provide anticipatory informed) and
guidance with participate in decision
patient/SO regarding tree.
treatment protocol, Accurate and concise
length of therapy, information helps to
expected dispel fears and
side effects. Be honest anxiety, helps clarify
with patient. the expected routine,
and enables patient
to maintain some
degree of control.

- Misconceptions about
cancer may be more
- Ask patient for disturbing than facts
Verbal feedback, and can interfere with
and correct treatments/delay
misconception about healing.
individual's type of
cancer and treatment.
- Provides ongoing
- Stress importance of monitoring of
continuing medical progression/ resolution
follow-up. of
disease process and
opportunity for timely
diagnosis and
treatment of
complications.
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

SUBJECTIVE: Impaired Skin SHORT TERM INDEPENDENT INDEPENDENT SHORT TERM

“Naggattel daytoy Integrity related to After 8 hours of nursing -Keep the area clean or -To assist the body’s After 8 hours of nursing
ayan ti sugat ko,” as surgical incision intervention the patient dry, carefully dress natural process of intervention the patient
verbalized by the and per-cutaneous and watcher will wounds, support repair. and watcher was able to
patient. describe measures to describe measures to
drain incisions, and prevent
protect and heal the protect and heal the
OBJECTIVE:
placement as tissue, including wound
infection through tissue, including wound
- 6 inch, evidenced by care. proper hand hygiene -Drainage of care.
horizontal disruption of and wearing gloves accumulated fluids -Goal met
surgical epidermis and LONG TERM when handling the (lymph, blood)
incision on the dermal tissue. After 3 days of nursing wound. enhances healing and LONG TERM
left breast with intervention the patient reduces the After 3 days of nursing
attached JP will display progressive -Assess wound drains, susceptibility to intervention the patient
drain improvement in wound periodically noting the infection. displayed progressive
- Visible redness or lesion healing amount and improvement in wound
on the part of characteristics of -To reduce risk of healing.
the incision and -Goal partially met,
drainage. dermal trauma,
surrounding ongoing
skin area warm improve circulation,
to touch. -Maintain and instruct and promote comfort.
in good skin hygiene
Vital Signs as (e.g., shower instead of
follows: bath, washing -to assist the body's
Temp: 37.1 C thoroughly, using mild natural process of
HR: 82 bpm nondetergent soap, repair.
RR: 16 bpm drying gently and
SpO2: 95% @ RA lubricating with lotion
BP: 120/80 mmHg or emollient, as -Reduces pressure on
indicated) compromised tissues,
which may improve
-Use appropriate barrier circulation and healing
dressings, wound and minimize
coverings, drainage lymphedema.
appliances, and skin-
protective agents for -Rubbing and
open, draining wounds scratching can cause
further injury and delay
-Encourage wearing healing. Rubbing the
loose-fitting or non- skin vigorously or
constrictive clothing. repetitively can cause
-Instruct the client to abrasions. It may lead
avoid rubbing and to skin breakdown,
scratching. Provide making the skin more
gloves or clip the nails if susceptible to infection.
necessary.
-A sterile technique
reduces the risk of
-Keep a sterile dressing infection in impaired
technique during wound tissue integrity. This
care. involves the use of a
sterile procedure field,
sterile gloves, sterile
-Assist in managing a supplies, dressing, and
wound drain. sterile instruments

-To assist in healing

-Refrain from and prevent infection
measuring blood
pressure in the affected - to prevent the
arm. potential of
constriction, infection,
and lymphedema on
the affected side.

DEPENDENT
-To manage and
prevent infection
DEPENDENT
Administer antibiotics
as ordered. EDUCATIVE
-Early assessment and
intervention help
EDUCATIVE
 -Teach the client and prevent the
caregiver about skin development of serious
and wound assessment problems. Signs of a
and ways to monitor for localized wound
signs and symptoms of infection include
infection, redness, warmth, and
complications, and tenderness around the
healing. wound. Purulent and
malodorous drainage
may also be present
(Ernstmeyer &
Christman, 2021).

-Accurate information
-Instruct client, increases the client’s
significant others, and ability to manage
family in the proper therapy independently,
care of the wound, reducing the risk of
including handwashing, infection and promoting
wound cleansing, healing of the skin.
dressing changes, and
application of topical -Nutrition plays a vital
medications. role in maintaining
intact skin and in
-Discuss the promoting wound
relationship between healing. Ascorbic acid
adequate nutrition is necessary for tissue
consisting of fluids, healing. Other nutrients
protein, vitamins B and associated with healthy
C, iron, and calories. skin include vitamin A,
B vitamins, zinc, and
sulfur.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

 Short-Term Goal: INDEPENDENT: INDEPENDENT: GOAL IS MET
Subjective: Acute pain related After 1-2 hours of 1. Positioned the - This will help the Short -Term Goal:
The patient to postoperative nursing interventions, patient in the right patient in reducing the The patient verbalized
verbalized “Nasakit procedure as the patient will be able side-lying position. pain in the operative a reduction in pain,
ngay jay evidenced by to verbalize decrease Additionally, make sure site. with an improved pain
naoperaan.” with a verbalized pain in pain scale of 3-4/10 to frequently change scale level of 3/10.,
pain scale of 7/10. with a pain scale from a current pain positions every 30 indicating
of 7/10. scale of 7/10 minutes. improvement.
Objective:
Guarding of post- Long-Term Goal: 2. Instructed to do deep - This will help reduce GOAL IS PARTIALLY
operative site After 3 days of breathing and educated tension and produce a MET
Facial Grimace rendering nursing on proper deep sense of tranquility for Long-term Goal:
Uncomfortable interventions; breathing technique. the patient.
The patient will be The patient
Vital Signs as able to verbalize 3. Monitored vital signs demonstrated
follows: decrease in pain scale regularly as follows cooperation with
Temp: 37.1 C of at least 0-3/10 heart rate, blood - Altered vital signs are nursing interventions
HR: 82 bpm The patient will be pressure, respiration, usually an indication of and expressed
RR: 16 bpm able to increase her and temperature. acute pain. understanding
SpO2: 95% @ RA left arm mobility regarding health
BP: 120/80 mmHg without complaints of 4. Encouraged teachings.
pain and with diversional activities - This can help distract Interventions
increased comfort such as listening to the the attention of the performed for of pain
radio. patient. management
techniques such as
DEPENDENT: DEPENDENT: proper positioning and
1. Assisted in wound - To promote healing facilitated pain relief,
care procedure and JP and prevent infection or contributing to the
Drainage measured. further complications. desired outcome.

2. Administered
medication for pain - Using pharmacologic
relief as per doctor's methods for pain
order. management would
help reduce the pain.