Assessment Nursing Scientific Planning Nursing Rationale Evaluation

Diagnosis Rationale Considerations

Subjective: Acute Pain Unpleasant Short Term: Independent -to promote Short Term
“Kumikirot at related to sensory and After 3 Hours -Provide comfort nonpharmacological Goal met as
masakit ang injuring agents emotional of NI client will measures pain management. evidenced by a
kanang paa as evidenced by experience experience decrease in pain
ko” as verbal report of arising from decrease -Note locatin of -this can influence and rate of the
verbalized by pain; coded actual or sensation of surgical procedures. the amount of pain scale of the
the patient report. potential pain through the postoperative pain patient
tissue damage help of -Accept client’s experienced, for
Objective or described in medications description of pain. example
>with surgical terms of such vertical/diagonal
dressing in the damage, Long Term” -Observe nonverbal ioncisions are more Long Term:
right leg sudden slow After 2 weeks cues/pain behaviors. paintful than Goal met as
>with onset of any of NI patient transverse or S evidenced by
colostomy intensity from will no longer -Monitor skin shape. absence of pain
>VS: mild to severe experince pain color/temp and VS in the patience
BP: 110/70 with an in his right leg -Pain is a subjective right leg.
RR: 19 anticipated or thorugh proper -Encourage adequate experience and
PR: 83 predictable breathing and test periods cannot be felt by
Temp:37 end and leg exercises. others.
duration of -Evaluate or
less than 6 document client’s -Observations may
months. response to not be congruent
analgesia. with verbal reports
or may be only
-Provide for indicator present
individualized when client is
physical therapy or unable to verbalize.
exercise program
 that can be -this usually altered
continued by the in acute pain.
client after
discharge. -to prevent Fatigue

Dependent -increase or
-Administer decrease dosage,
Analgesics as stepped program
ordered. helps in self
management of
Interdependent pain.
-instruct or
encourage use of -Promotes active,
relaxation not passive, role
techniques such as and enhances sense
foucused breathing of control.

Dependent
-to maintain
“acceptable” level
of pain.

-to distract attention

and reduce tention.

Assessment Nursing Scientific Planning Nursing Rationale Evaluation

Diagnosis Rationale Considerations
Objective: Risk for It is an Short Term: Independent: -A first line of Short Term:
-the patient has infection increased for After 8 hours of -Stress proper hand defense against Goal met as
surgical related to tissue being invaded NI client will be hygiene by all healthcare evidenced by
dressing destruction, by pathogenic free from caregivers between associated absence of
-colostomy increased organisms. microrganisms therapies/client. infections. microorganisms
bag present. environmental through the help -Provide isolations -Reduces risk of on the patient’s
V/S: exposure to of medications as indicated. cross- wounds.
BP:110/70 pathogens; such as -Cover contamination.
RR:21 invasive Prophylactic perineal/pelvic -to prevent
PR:80 procedures as Antibiotics region dressing/casts contamination.
Temp:36.7 evidenced by with plastic when
surgical using bed pan. -reduces risk of
wounds with Long Term: ascending UTI. Long Term:
dressing and After 1 week of -Provide regular Goal met as
colostomy bag. NI the client urinary catheter/ Interdependent: evidenced by the
will be free perineal care -to prrevent patient learned
from organisms pneumonia. how to manage
through proper -Emphasize proper hygiene
health teaching necessity of taking or care for the
of caring for antivirals/antibiotics, his wounds and
his surgical a as directed the colostomy
wounds and bag
colostomy bag. -continue treatment
when client begins
to feel well may
result in return of
infection and
potentiate drug
resistant strain/
secondary
infections.

Interdependent:
-Assist with the use
of adjuncts.

Dependent:
Administer
prophylactic
antibiotics and
immunizations as
indicated.

-Change
surgical/other
wound dressings as
indicatred using
proper techniques
for
changing/disposing
contaminated
materials.