Nursing

Assessment Planning Intervention Rationale Evaluation

diagnosis
Subjective: "pakiramdam ko Fatigue Report Note age, gender, and developmental Since studies show prevelance in After hours
ay kalos na kalos ako, r/t improved stage. fatigue and even wound healing of nursing
parang pagod na pagod surgical sense of varies from age, gender, and intervention
kahit kakagising ko lang." stress energy developmental stage. the Px will
as verbalized by the px. verbalize
Perform ADLs Assess characteristics of surgical wound Infectious process may manifest improved
Objective: and for any manifestations of infections like fatigue since body is being energy. And
 Weakness participate redness, swelling and/or purulent compromised. Px would
indesired discharge. be able to
 Irritability activities at do ADLs at
level of ability Assess surgical site for any abnormalities Due to trauma from surgery tissues level of
 Lethargic / of functioning like swollowing, and/or may swell and cause inflammation tolerance.
Deficient in talking. which may alter ADL like eating.
alertness or
activity Assess characteristics of fatigue, like its To compare changes in the patient’s
Severity, Changes in severity over time, fatigue level over time. It is important
 Uncooperative Aggregating factors, Alleviating factors by to determine if the patient’s level of
using quantitative rating scale fatigue is constant or if it varies over
 Compromised time.
concentration
Assess the patient’s nutritional intake of Fatigue may be a symptom of protein-
 Exertional calories, protein, minerals, and vitamins. calorie malnutrition, vitamin
discomfort deficiencies, or iron deficiencies.

The patient will need adequate intake of
 Impaired ROM
carbohydrates, protein, vitamins, and
minerals to provide energy resources.
The patient will need adequate intake
of carbohydrates, protein, vitamins,
and minerals to provide energy
resources.

Assist the patient to develop a schedule for A plan that balances periods of activity
daily activity and rest. with periods of rest can help the
patient complete desired activities
without adding to levels of fatigue.
 Encourage the patient to identify tasks that
can be delegated to others.
Ascertain clients belief about what is
causing the fatigue.
Evaluate the patient’s sleep patterns for
quality, quantity, time taken to fall asleep,
and feeling upon awakening.
Assess the patient’s emotional response to
fatigue. Psychological and personality
factors that may affect reports of fatigue
level.
Assess the patient’s expectations for
fatigue relief, willingness to participate in
strategies to reduce fatigue, and level of
family and social support.
Minimize environmental stimuli, especially
during planned times for rest and sleep.
Assessment Nursing Planning Intervention
Delegating tasks and responsibilities
to others can help the patient conserve
energy.
Some fatigues are psychologically
induced.
Fatigue can be a consequence of, &/or
exacerbated by, sleep deprivation.
Anxiety and depression are the more
common emotional responses
associated with fatigue. These
emotional states can add to the
person’s fatigue level and create a
vicious cycle.
The patient will need to be an active
participant in planning, implementing,
and evaluating therapeutic
interventions to relieve fatigue. Social
support will be necessary to help the
patient implement changes to reduce
fatigue.
Bright lighting, noise, visitors, frequent
distractions, and clutter in the patient’s
physical environment can inhibit
relaxation, interrupt rest/sleep, and
contribute to fatigue.
Rationale Evaluation
 diagnosis
S-Ø Risk for Desired outcome: Independent: After series of
O- infection At the end of the Establish px rapport To gain patients trust. nursing
(+) incision site related to nursing intervention
on the neck surgical interventions the Monitor Vita signs To report any significant or various patient will
incision on pt. will: changes in the Px condition. verbalize
Received pt. on the neck increased comfort
side lying Be informed the Assess patient's incision site for any sign of To notify attending physician for any and knowledge
position preventive infection such as warmth, redness and s/sx of infection. about care of his
measured of dec. purulent exudate. wound and its
Emaciated the risk of significance to
infection. Provide quiet and relaxing environment. Quiet environment helps the patient his/her condition.
Dry skin & lips to relax and rest properly. It also
Feel comfortable provides comfort.
Pallor & relaxed
Teach the patients relative on how to Providing proper hygiene makes the
Dry hair Incision site will provide proper hygiene. patient relaxed and comfortable. It
be free from also decreases the risk of infection.
Poor skin turgor pathogenic
upon pitching microbes Maintain client on side-lying position. To prevent aspiration.

Dec. ROM Objectives: at the Dependent:

end of the nsg. Cleanse incision site daily or prn as To reduce existing r/f.
intervention the ordered by the doctor.
pt. will improve
current physical Assist with medical procedure such as To reduce existing r/f.
coping wound aspiration as indicated.
mechanism to
his/her condition. Administer prophylactic antibiotic, as Reduce r/f and help px to physically
ordered by the doctor. cope with present condition.

Assessment Nursing Planning Intervention Rationale Evaluation

 diagnosis
S-Ø
O-
Impaired Desired
outcome:
Independent:
Establish px rapport To gain patients trust.
After series of
nursing
(+) incision site swallowing At the end of intervention
on the neck the nursing Provide cognitive cues such as reminding To enhace concentration and patient will be able
r/t to interventions client to chew or swallow. performance of swallowing to swallow
Received pt. on
side lying
surgical the px will
demonstrate
sequence and to enhance
swallowing ability to meet fluid and
accordingly and
would have an
position incision on feeding caloric body req. increased
methods appetite.
Lack of the neck appropriate to Encourage a rest period before meals. To minimize fatigue.
chewing. his or her
situation. Remain with client during meal. To reduce anxiety and offer
Long meals with assistance.
little
consumption. Monitor intake, output and body weight. To evaluate adequacy of fluid and
caloric intake.
Observed Dependent:
evidence in diff Refer to dietician regarding px conditon . To provide appropriate nutrition for
of swallowing. the patient.

Incomplete lip
closure

Dry skin & lips

Dec. ROM