Assessment Subjective: " Hindi Ako Makatulog Kapag

Assessment Nursing Outcome Planning Intervention Rationale Evaluation
Diagnosis Identification
Subjective: Sleep pattern After 8 hours of Independent
“ Hindi ako disturbance nursing - to identify factors -Noted and identified - to lessen Met
makatulog related to intervention the affecting sleeping circumstances that interruptions of identified factors
kapag sumasakit interruption of patient will be pattern. interrupt sleeping pattern. sleep and promote affecting sleep.
ang sugat ko” as sleep when pain able to restful
verbalized by the at lumbar area verbalized environment.
patient. occurs as improvement in
manifested by sleeping pattern. - to identify sleep and - Determine pt’s -To provide Partially Met
Objectives: irritable and dysfunction. expectation of adequate opportunity to Pt’s expectation of
restless. sleep. address adequate sleep
BP- 100/70 misconception. was determined
T- 36.9 but doesn’t have
PR- 72 time to explain.
RR- 22
- to assist patient -Observe pt’s usual - to determine Met
-irritable establish optimal bedtime routine and no. Of usual sleeping Sleeping pattern
-restless sleep pattern hours of sleep. pattern and was determined.
provide
comparative
baseline.
- Give appropriate bedtime - to enhance pt’s Unmet

meal before sleep (warm ability to fall Doesn’t have time
milk will do). asleep. to provide for
bedtime meal.
-to promote wellness. - Recommend morning - napping in the Met

nap. afternoon may Morning nap was
interrupt sleep in recommended.
the evening.
Assessment Nursing Outcome Planning Intervention Rationale Evaluation
Diagnosis Identification
Independent:
Subjective: Impaired skin After 8 hours of -To assess the -Monitored vital signs -Serves as a baseline data MET.
“Inoperahan Integrity related nursing characteristics Vital signs taken and
ako sa tiyan” to surgical intervention the of the suture. -Rechecking of the recorded.
as verbalized operation (Total patient will condition of the -early recognition of delayed
by the patient. abdominal achieve timely incision healing and developing of Partially MET.
hysterectomy wound healing the wound may prevent more The wound was not
bilateral without serious complications closely monitored
O: -Sutures at salpingo- complications.
the low oophorectomy)
midline of as manifested by -Cleansed and -Protects from the MET.
abdomen incision at the -To promote changed the dressing contamination and prevents The dressing of the
low midline of wound accumulation of fluid that wound was changed
-7cm length of the abdomen healing may cause excoriation. and cleansed
incision
-Instructed on proper -To promote self care.
-Presence of wound dressing MET.
dressing The patient was
taught about wound
- break in the dressing
skin integrity.
Dependent:
-Administered -To promote wound healing MET.
medications as and prevent infection Due meds given
ordered. Amoxicillin
1g TIV.
MET.
-Instructed to attend -To check the healing The patient was
follow up checkup progress of the wound and instructed to attend
the removal of sutures follow up check-up
Assessment Nursing Diagnosis Outcome Planning Intervention Rationale Evaluation
Identification
Independent:
S:” Kumikirot ang Alteration in Will be able to -To assess the level -Monitored Vital -To serve as Met.
sugat ko” as comfort: Pain decrease feeling of pain signs baseline data Vital signs taken
verbalized by the related to surgical of pain from 7 and recorded.
patient. incision secondary to 3 after 30 -Determined pain
to status post Total minutes of characteristics such as -To assess the Met.
P – movement abdominal nursing provoking factors, degree of pain. PQRST taken.
Q –Stabbing pain hysterectomy intervention. quality of pain,
R- from area of bilateral salpingo- region, scale and
incision site oophorectomy duration
S- 7/10 operation as
T- 30 mins. evidenced by pain
scale of 7 -Provide conducive -Instructed for bed -To conserve Met.
O: environment. rest. energy. Patient was
- Irritability instructed.
- Guarding
behavior -To help patient -Attached an -To relieve pain Met.
- Facial grimace lessen the abdominal binder and to keep suture Abdominal binder
occurrence of pain. intact. was attached
-Encouraged patient - to divert patient’s Met

- to have divertional attention when pain patient was
activities when pain occurs. encouraged to have
occurs. divertional
activities
Dependent:
 Administer -To relieve pain Met.
Nubain 500 mg from the incision. Due meds given
TIV

Assessment Subjective: " Hindi Ako Makatulog Kapag

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Assessment Nursing Outcome Planning Intervention Rationale Evaluation

- Give appropriate bedtime - to enhance pt’s Unmet

-to promote wellness. - Recommend morning - napping in the Met

-Encouraged patient - to divert patient’s Met

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