Nursing Care Plan Post Op & Intra Op

Assessment

Nursing Rationale Goal/Objective Diagnosis Subjective: Pain related to Pain is one of  Goal: Patient verbalized abdominal the mos t After 8 hours of  “masakit yung tahi dito sa surgical incision complex human nursing tiyan ko. Mga 5 ang sakit (on abdomen experiences, is intervention niya pero kaya ko pang with a surgical an invisible  patient will tiisin. Sumasakit lang siya incision of 4  phenomenon report a decrease  pag may kinakain ako o inches) influenced by of pain from 5 to kaya pag masyado akong manifested by the interaction 4 and below. gumagalaw.” verbal report of  of emotion,  pain & guarding  behavioral, Objective: Objective cues:  behavior. cognitive and After 4 hrs. Assessed pain scale,  physiologic patient will be dressing is not soaked of  sensory factors. able to:  bloody discharge, Because pain is - demonstrate guarding behavior noted a highly different when patient moves, facial individual relaxation grimace noted experience, the techniques to  basis for pain decrease pain management is - understand a simply the need for rest client’s  period after each verbalization of  activity done.  pain. Fundamental of  nursing, CRAVEN p 1168

Intervention Diagnostic Assess pain scale

Monitor vital signs

Therapeutic: -Provide a quiet environment - Assist patient during activities -Administer analgesic if  indicated

Health Teaching: - Emphasize importance rest periods after every activity

Rationale

Evaluation

Goal: Helps to determine After 8 hours of  effectiveness of therapy nursing intervention for pain  patient verbalized To monitor if there are  pain scale of 3 any changes Objective: After 4 hrs. patient To minimize stress that was able to:  patient is experiencing - demonstrate To minimize feeling of  different relaxation  pain techniques to To provide relief  decrease pain through drug - understand a need interaction for rest period after  each activity done For client to understand that rest periods after  each activity will relieve stress, muscle tension & increase relaxation

INTRA-OP

Assessment Objective cues: Patient’s vital signs is closely monitored, patient is in a supine position, the abdomen is exposed

Nursing Diagnosis Risk for  infection related to surgical  procedure manifested by surgical instruments introduced in the  body

Rationale

Goal/Objective

Any invasive Goal: device that After 8 hours of  enters the body nursing  provides a portal intervention of entry for   patient will not microorganisms, manifest signs thus increasing and symptoms of  the chance infection during infection. the whole Fundamental of   procedure. nursing, Craven  p 1039 Objective: After 4 hrs the  patient will be able to recover  from surgery without any complications. -will be able to understand importance of  well-balanced diet.

Intervention Diagnostic Monitor vital signs

Assess incision site Therapeutic: - Provide a clean environment - minimize touching the incision -Administer antibiotics if  indicated

Health Teaching: -instruct patient & family importance of well balanced diet high in  protein calories. -discuss sources of vitamin C & vitamin supplements

Rationale

Evaluation

Goal: Helps to determine After 8 hours of  effectiveness of therapy nursing intervention for pain  patient did not To monitor if there are manifest signs and any changes symptoms of  infection during the whole procedure & To minimize stress that after the procedure.  patient is experiencing To minimize feeling of  Objective:  pain After 4 hrs the To provide relief   patient was able to through drug recover from interaction surgery without any complications. Wound healing -was able to requires protein & understand calories for building importance of wellnew cells. The immune  balanced diet. system depends on  protein & calories to  produce antibodies.