ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective “Risk for infection Short term Independent 1. Gain a good After 1-2hours of
Data: related to post- After 1- 1. Establish trust patient-nurse nursing care, goal is
- operative surgical 2hours of and rapport. relationship. partially met. The
procedure nursing care, 2. Monitor vital 2. To gather patient was able to
hemorrhoidectomy client will be signs. baseline data understood
Objective secondary to able to 3. Encourage observations. causative factors
Data: exposure to wet understand client to observe 3. To boost that may
-Open wound environment” the good hygiene. good self- contribute to
incision at the causative 4. Instruct to esteem. infection.
inguinal area factors that observe proper 4. To prevent
VS taken as may handwashing infection and
follows: contribute techniques. contamination.
T 36.1 to infection. 5. Instruct to 5. Note the After days of
HR 72 observe for signs risk factors for
nursing
RR 16 Long term and symptoms of occurrence ofintervention, goal
BP 110/70 After days of infection. infection. is fully met. The
O2 99% nursing 6. Instruct to 6. To preventpatient are able to
intervention, change dressings infection. understood her risk
client will be as often as for infection after
able to possible. surgery and was
understand able to
her risk for demonstrate
infection techniques in
after surgery Dependent preventing
and will be 7. Administer 7. It is an infection after
able to Cefuroxime as antibiotic drug surgery.
demonstrate prescribed by the which kills or
techniques physician. prevents
in growth of
preventing bacteria and
infection prevent
after possible
surgery. infection.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective “Acute pain Short term Independent 1. Gain a good After 1-2hours of
Data: related to post- After 1-2hours 1. Establish trust patient-nurse nursing care, goal
“Masakit yung operative of nursing care, and rapport. relationship. is partially met.
sa may anal surgical patient will be 2. Monitor vital 2. To gather The patient was
area ko, procedure in the able to report signs. baseline data able to report
medyo anal area as pain is relieved 3. Provide observations. controlled pain
nagwworry po evidenced by or controlled comfort 3. To distract and verbalized
ako paalis verbalization of and verbalize measures, calm attention and non-
yung pain by the non- and therapeutic reduce pharmacological
nakainsert patient and pharmacologica environment, tension. methods that
do’n” irritability” l methods that and diversional 4. To promote provide relief.
provide relief. activities. relaxation.
4. Instruct to use 5. To relieve
Objective Long term relaxation discomfort
Data: After days of techniques, such from perineal After days of
-Irritability nursing as deep area. It also nursing
-Restlessness intervention, breathing. promotes intervention, goal
-Facial client will be 5. Instruct to healing or is fully met. The
grimace able to verbalize engage in hot surgical sites. patient was able
VS taken as she is free from sitz bath three 6. It could to verbalized that
follows: pain and will times a day at compromise she is free from
T 36.1 show signs of least 10- stitches or pain and shown
HR 72 relaxation and 15minutes. affect the signs of comfort.
RR 16 comfort. 6. Advised not area’s healing
BP 110/70 to bear down processes.
O2 99% during
defecating.

Dependent 7. To help
7. Administer relief pain.
analgesics as 8. It helps
prescribed by improve
the physician. digestion and
8. Advised to can prevent
increased high constipation.
fiber diet as It also soften
prescribed by stools.
the physician.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective “Altered comfort Short term Independent 1. Gain a good After 2-3hours
Data: related to pain After 2-3 hours 1. Establish trust patient-nurse shift, goal is
“Ayoko muna secondary to shift, patient and rapport. relationship. partially met. The
umupo post-operative will be able to 2. Monitor vital 2. To gather patient was able
nahihirapan surgical verbalize signs. baseline data to verbalized
ako kasi procedure” measures that 3. Promote rest observations. measures that can
masakit, can help relief periods. 3. To provide help relief pain
ngalay na din pain, and most 4. Modify the relaxation and and improved
ako humiga” importantly, environment by comfort. comfort.
improve changing room 4. A conducive
comfort. temperature, environment
Objective eliminate promotes
Data: distracting noise healing and
-Irritability Long term if possible. relaxation. After days of
-Facial After days of 5. Assist patient 5. To provide nursing
grimace nursing in her desired comfort and intervention, goal
VS taken as intervention, position wherein relief. is fully met. The
follows: client will be she is most 6. To divert patient was able
T 36.1 able to verbalize comfortable. the attention to verbalized she
HR 72 she is free from 6. Instruct to any of the patient. is free from pain
RR 16 pain and diversional and discomfort.
BP 110/70 discomfort. The activities and The patient was
O2 99% patient will also measures that also able to
be able to can help relief display
display discomfort. improvement in
improvement in mood.
mood.
Dependent 7. To help
7. Administer relief pain that
analgesics as will provide
prescribed by comfort to the
the physician. patient.