ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: 1. Acute pain  To relieve pain 1. Determine/document presence of  To identify the  Patient
“Masakit pa rin po related to felt by the possible pathophysiological or possible causes of pain verbalized
yun inoperahan sa post patient or to psychological causes of pain. felt by the patient. that the
bandang babang operative alleviate pain Example: inflammation, infections, abdominal
kanan ko”, as operation such as abdominal conditions such as pain was
verbalized by the secondary lowering pain appendicitis. minimized.
patient. to level from 8/10 2. Assess for referred pain as  To help determine The patient
appendect to 3/10. appropriate. possibility of also rated the
Objective: omy underlying condition pain in pain
• (+) verbalization  To learn or organ-dysfunction. scale as 3/10.
of pain felt by techniques that 3. Note client’s attitude towards to pain  Individuals the
the patient on may alleviate and use of pain medications including external focus of  The patient
the lower right the pain felt by any history of substance abuse. control may take little also learned
quadrant of the the patient. or no responsibility for to use
abdomen. pain management. relaxation
• Guarding 4. Administer pain medications.  Administer pain techniques
behavior noted medications such as such as deep
upon palpation morphine sulfate or breathing
on the affected analgesics. exercise and
part which is the 5. Encourage diversional activities (e.g.  Distracts the patient other
abdomen. TV/radio, socialization). focus on the pain on diversional
• Verbalization of the incision site. activities that
pain scale of 6. Determine factors in client’s lifestyle may help the
 They need to be
8/10. (e.g. alcohol/other drug use/abuse) patient
known by the nurse as
• Vital signs which affect responses to analgesic). alleviate the
some individuals may
taken: have history of pain even the
BP- 130/80 drug/substance abuse out using
T-36.8 or dependency or pharmacolog
R- 24 which may affect the ical therapy.
P- 72 effects of analgesics.
7. Instruct in/encourage use of
relaxation techniques such as focused  Distracts patient’s
breathing imaging. attention on the pain
and reduces tension.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: 1. Risk for  Identify 1. Observe for localized sign of  To know whether the patient  Patient was
“Apat na araw na infection interventions infection surgical for an infection or an able to
po akong related to to prevent incisions/wounds. infection has stared identify
naoperahan hindi ko insufficien reduce risk of especially for patients whose interventions
masyadong nalilinis t infection. case requires a surgical that may
ang sugat ko”, as knowledg incision and to help the prevent
verbalized by the e to avoid patient to become aware and wound
patient. exposure for early prevention. infections
to 2. Teach patient to do proper hand  To prevent infection from his such as doing
Objective: pathogens washing before holding his hands to his wounds. proper
• Dirty wound wound. wound care
noted. 3. Teach patient to do proper  For the patient to be aware everyday and
• Post-op wound wound care. on how to do proper wound proper hand
dressing soaked care and even when he is washing
with discharge he would still be every time
serosanginous able to clean his wound. doing wound
drainage from  Demonstrate 4. Instruct the client/SO in  Keeping the integrity of the care.
the post- techniques infection techniques to protect skin is a vital requirement for
operative lifestyle the integrity of skin and prevent preventing wound infection  Patient also
incision. changes to of infection. because a wound that is not demonstrated
• (+) verbalization promote safe dry and clean may harbor techniques
of non- environment infection. and lifestyle
compliance of and for 5. Discuss client’s importance of  Premature discontinuation of such as strict
cleaning of prevention of taking anti-bacterial and anti- treatment when client begins compliance
wound. wound viral. to feel well may result in of taking
infection. return of infection and prescribe
potentiate drug resistant antibacterial.
strains.
6. Use Chlorampenicol  to prevent bacteria harbor in
Sodium(antibiotic) as ordered operative site
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: 1. Irregular  Establish/regain 1. Review daily dietary  To evaluate whether the  Patient
“Iregular po ang bowel normal pattern of regimen, noting if the diet is patient has deficient fiber verbalized that
pagbabawas ko movement bowel deficient in fiber. intake because fiber he/she has no
Ma’am minsan related to functioning. intake increases bulk of problem in
nahihirapan po inflammatio the stool and facilitates defecating
akong magbawas at n of the peristalsis. anymore and
kung minsan aman lower 2. Instruct/promote adequate  To promote passage of he/she has also
po nagtatae ako”, as gastrointesti fluid intake including high stool. not experiencing
verbalized by the nal (colon) fiber, fruit juices, suggest diarrhea. He also
patient. secondary to drinking warm, stimulating learned about
thickening fluids. (e.g. tea, coffee) the specific
Objective: of muscular 3. Encourage/perform the  To stimulate contractions interventions to
• (+) abdominal strictures patient exercises that may of the intestines/to take the next
bloating improve abdominal muscle promote peristalsis. time the
• Guarding tone. recurrence of
behavior noted 4. Administer stool/bulk  To decrease straining at problem occurs.
upon palpation laxatives softeners as stool this may lead to He also learned
on the left lower prescribed. decrease intestinal about the
quadrant of the pressure. importance of a
abdomen.  Demonstrates 5. Identify specific actions to be  To promote timely lifestyle change
• (+) verbalization behaviors or taken if problem recurs. intervention, enhancing in his/her
of episodes of lifestyle changes client’s independence. condition.
irregular bowel to prevent 6. Provide information about
movement with recurrent of relationship of diet, exercise,
 To increase knowledge
episodes of problem fluid, and appropriate use of
the activities and lifestyle
diarrhea. laxatives, as indicated.
changes that may prevent
• Distended the recurrence of the
abdomen noted. disease.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: 2. Acute pain  Reports pain is 1. Determine/document  To determine the  The patient
“Masakit po ang related to decreased to tolerable presence of possible causes of pain and on verbalized that
tiyan ko Ma’am, inflammatio level. pathophysiological causes how to cure the pain the pain was
lalo n apo sa babang of pain. and whatever triggers
n of reduced from
kaliwang bahagi po it.
ng aking tiyan “, as intestinal 2. Administer opiod  To relieve the pain of 8/10 to 3/10 of
verbalized by the mucosa analgesics (e.g. diverticulitis and pain scale.
patient. secondary Meperidine) as prescribed. spasms. He/she was also
to infection 3. Provide comfort measures  To promote non- able to identify
Objective: (e.g. touch, repositioning pharmacological pain and perform the
• (+) abdominal use of heat/cold packs). management. difference non-
bloating on the 4. Encourage use of  To distract attention
relaxation techniques such pharmacological
left lower and reduce attention.
quadrant. as imagery, focused medications for
• (+) verbalization breathing. pain.
of pain with a 5. Review ways to lessen  To explore other  The SO/s where

pain scale of pain including techniques methods that may help
8/10 . such as therapeutic touch, able to identify
reduce pain even if
• Guarding biofeedback and non-pharmacologic and the difference
behavior noted relaxation skills. for the patient may use activities that
upon palpation even if he/she is may trigger the
on the abdomen. discharged from the patients
• Facial grimace hospital.
6. Discuss the SO ways in abdominal
noted.  To avoid patient from
which that can assist client discomfort.
• Bloated experiencing pain that
abdomen noted. and reduce precipitating
may be trigger
factors that may cause or
increase pain.
 ASSESSMENT DIAGNOSIS PLANNING  INTERVENTION RATIONALE EVALUATION
Subjective: 1. Acute pain  Reports pain is 1. Perform comprehensive  To assess the severity  The patient
“Masakit po ang related to relived or assessment of pain to include of pain the patient is verbalized that
puwet ko pag inflammati controlled to a location, characteristic, experiencing and for the pain he/she
nagbabawas po ako quality, severity (pain scale). the nurse to determine
on and tolerable level. felt was relived
at minsan po pansin the extent of
kong may dugo yung edema of and he/she was
intervention for pain
dumi ko at may prolapsed the nurse will give. also able to
parang may laman na varices 2. Determine possible causes of  To determine the cause control the pain
naka umbok sa pain (e.g. inflammation, of pain. that he/she was
puwet ko”, as surgery, herniated, etc.). feeling. He/she
verbalized by the 3. Perform pain assessment  To rule out worsening was also able to
patient. each time pain occurs. Note of underlying
and investigate changes from identify the
condition/development
Objective: previous reports. different ways
of complication.
• (+) verbalization 4. Administer stool softeners as and technique to
 To reduce straining
of pain upon doctors prescribed. during defecation as it relieve.
defecation. produces pain when
• Palpable mass straining.
noted on the anal 5. Do hot sitz bath with the
 To reduce pain on the
area. patient.
anal area.
• Blood streaked  Verbalize a method 6. Demonstrate different
 For the patient to
stool noted upon diversional activities that
that provides relief. identify ways how can
defecation. may help alleviate pain such
he/she alleviate pain.
• Straining when as watching television,
defecating and reading, avoiding foods that
associated with may cause constipating.
pain. 7. Encourage patient to practice
 To prevent infection on
hygiene specifically on the
the hemorrhoids this
anal area.
may cause more pain
on the affected area.