ACUTE PAIN

ASSESSMENT EXPLANATION OF THE

PROBLEM
GOAL/OBJECTIVE INTERVENTION RATIONALE EVALUATION
S> Nasakit daytoy
naoperaan, reported
pain over the surgical
wound.
> Rated pain as 7/10,
with 10 denoting the
worst pain level,
described as
lacerating pain and
aggravated by
sudden movement.

O> Grimace noted
> With guarding
behavior over the
operative site
> With dry and intact
dressing on the
operative site
> Vital signs taken as
BP 110/70 mmHg,
temp 36.1
o
C, RR
20cpm, PR 71 bpm.

Acute Pain related to
traumatized tissues
secondary to s/p EX-
LAP and colostomy

Complex responses
of tissue and nerve
endings due to trauma
from surgery(incision)
and cause
hypersensitivity to the
central nervous system
that causes unpleasant
physical and
emotional reactions and
responses.


Short term objective:
>After 1 hour to 1 hour
and 30 minutes patient
will report relief of pain
from 7/10 to 3/10
>Demonstrate proper
Deep Breathing
exercises and other
non-pharmacological
techniques to relieve
pain



Long term objective:
After 2 days of nursing
intervention the
patient will;
>Report relief of pain
from 7/10 to 1/10


Dx>Monitor vital signs.




>Obtain clients
assessment of pain
status and
characteristics


>Observe non-verbal
cues.


>Assess intactness and
dryness of dressing.



Tx>Establish
therapeutic
communication with
the client.
> Provide comfort
measures (e.g., touch,
repositioning, nurses
presence), quite
environment and calm
activities.
- Provides baseline
data for future
comparison and
are usually altered
in acute pain.
- To rule out
worsening of
underlying
condition/
development of
complications.
- Patient may be
reluctant to tell the
nurse about his
discomfort.
- To note for other
complications that
may arise like
infection on the
operative site.
- To establish trust
and cooperation.


- to promote non-
pharmacological
pain management



Short term goal:
> The goal was fully
met. Patient reports
relief of pain from 7/10
to 3/10

Long term goal:
> The goal was fully
met. Patient reports
relief of pain from 7/10
to 1/10. Patient was
also able to perform
deep breathing
exercises and other
non-pharmacological
techniques to relieve
pain.

> Provide patient with
opportunities to rest.
> Administer pain
medications as
ordered by the
physician.
>Teach client to
perform DBE when in
pain.

Edx> Encourage
adequate rest period.
>Encourage
verbalization of
feelings and concerns
regarding health
status.

>Encourage early
ambulation.



>Encourage
progressive activities of
daily living as tolerated
with periodic rest
periods.


>Encourage use of
relaxation techniques
such as focused
breathing, imaging,
- Allows patient to
regain strength.
- To decrease pain.



- Promotes
relaxation and for
optimum oxygen
circulation.
- To prevent fatigue

- To determine other
factors that may
contribute to pain
or may lead to
possible
complications.
- To promote blood
circulation and
stimulates peristalsis
and passing of
flatus.
- Prevents fatigue,
promotes healing
and feeling of well-
being and
facilitates
resumption of
normal activities.
- To distract
attention and
reduce tension.

CDs/music player(
e.g., music, reading
materials)



















ANTICIPATORY GRIEVING
ASSESSMENT EXPLANATION OF THE
PROBLEM
GOAL/OBJECTIVE INTERVENTION RATIONALE EVALUATION
S>han ko
ekspektaren nga ada
cancer ko nga stage
4 dagus, hank ko
pailang matangap

O>Blank and
morbid expression
>seldom smiles
>seldom talks
>always in deep
thoughts
>withdrawn behavior
>apathetic behavior

Anticipatory grieving
related to perceived
potential death
secondary to Stage 4
colon cancer vs.
metastasis


A cancer diagnosis
need not indicate a
fatal outcome. Many
forms of cancer are
curable, while others
may be cured or
controlled for long
periods of time is
treated early. Despite
these facts, many
patients and their
families view cancer as
a fatal disease that is
inevitably
accompanied by
pain, suffering,
debilitation and
emaciation. Grieving is
a normal response to
these fears and to
actual or potential
losses: loss of health,
normal sensations,
body image, social
interaction, sexuality
and intimacy. Patients
families and friend
may grieve for the loss
of quality time to
spend with others, the
Short term objective:
After 8hrs of nursing
intervention the client
will:
- Verbalize reality
and acceptance
of situation
- Identify and express
feelings of guilt,
anger and sorrow
- Identify physical
problems
associated with
anticipatory grief

Long term objective:
After 3days of nursing
intervention the client
can continue normal
life activities, look
toward and plan for
future, one day at a
time.
Dx> Assess the patient
for any evidence of
suffering including
pain and point of view
of the world around
them.




> Assess client and SO
for stage of grief
currently being
experience.






> Expect initial shock
and disbelief ff. dx of
cancer and/or
traumatizing
procedures.
> Assess emotional
state. Note cultural
beliefs, expectations.


- Suffering includes
pain and the
patients point of
view of their world
around them.
Asking about
suffering can help
to relieve it merely
by acknowledging
its existence.
- Knowledge about
the grieving
process reinforces
the normalcy of
feelings and
reactions being
experienced,
helping client deal
more effectively
with them.
- Few clients are fully
prepared for the
reality of the
changes that can
occur.
- Anxiety and
depression are
common reactions
to changes/losses
associated with
Short term objective:
After 8hrs of nursing
intervention goal met
if the client will:
- Verbalize reality
and acceptance
of situation
- Identify and
express feelings of
guilt, anger and
sorrow
- Identify physical
problems
associated with
anticipatory grief

Long term objective:
After 3days of nursing
intervention, goal met
if the client can
continue normal life
activities, look toward
and plan for future,
one day at a time.
loss of future and
unfulfilled plans, and
the loss of control over
the patients body and
emotional reactions.



>Be aware of mood
swings, evidence of
conflict, expressions of
anger or hostility, and
other acting-out
behavior.




>Identify positive
aspects of the
situation.




Tx>Provide open,
nonjudgmental
environment. Use
therapeutic
communication skills of
active-listening, and
acknowledgement.
>Encourage
verbalization of
thoughts and
concerns, accepting
expressions of sadness,
anger, and rejection.
Acknowledge
long-term illness or
debilitating
condition.
- May be clients
way of expressing
or dealing with
feelings of despair
and spiritual distress
reflecting
ineffective coping
and need for
additional
interventions.
- Opportunity to
identify skills that
may help
individuals cope
with grief of current
situation more
effectively.
- Promotes and
encourages
realistic dialogue
about feelings and
concerns.


- Client may feel
supported in
expression of
feelings by the
understanding that
deep and often
conflicting
normalcy of these
feelings.




Edx>Reinforce
teaching regarding
disease process and
treatment. Be honest;
do not give false hope
while providing
emotional support.
Review past life
experiences, role
changes, and coping
skills.
>Encourage
participation in care
and treatment
decisions.
emotions are
normal and
experienced by
others in this difficult
situations.

- Client and SO
benefits from
factual information.
Honest answers
promote trust and
provide
reassurance that
corrects
information will be
given.

- Possibility of
Remission and slow
progression of
disease and/or
new therapies can
offer hope for the
future.






IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
ASSESSMENT EXPLANATION OF THE
PROBLEM
GOAL/OBJECTIVE INTERVENTION RATIONALE EVALUATION
S> mejo naawan
ganas ko mangan, nu
marikank ti bisin ko ket
bassit lang ti makan
ko

O> Weight loss from 65
kg to 61 kg
>Loss of muscle mass
>Poor muscle tone
>Lack of interest in
food
>24 hours post-op NPO

Imbalanced nutrition,
less than body
requirement related to
lack of appetite and
dietary restriction

Imbalanced nutrition:
less than body
requirements refer to
an intake of nutrients
insufficient to meet
daily requirements
because of
inadequate food
intake or improper
digestion and
absorption of food. An
inadequate food
intake may be caused
by the inability to
acquire or prepare
food, inadequate
knowledge about
essential nutrients and
a balanced diet,
discomfort during or
after eating,
dysphagia, anorexia,
nausea, or vomiting.
Improper digestion
and absorption of
nutrients may be
caused by an
inadequate
production of
hormones or enzymes
Short term objective:
After 8 hours of Nursing
Interventions, the
patient will be able to
increase his appetite
to meet normal
metabolic demands.

Long term objective:
After 2 days of
continuous Nursing
interventions, the
patient will be able to
demonstrate
improvement in skin
integrity and skin color,
stronger muscle tone
and sustain usual diet
necessary for weight
gain.
Dx>Assess the client
dietary status

>Assess for factors
contributing to altered
nutritional intake
(nausea and vomiting,
depression)

>Record actual
weight; do not
approximate.




>Observe or discover
manners toward
eating and food.






Tx>Advocate rest
before meals.



- Provide a data
about dietary
status
- Information about
other factors that
may be altered to
promote adequate
dietary intake is
provided
- Patients may be
unconscious of
their actual weight
or weight loss
because of
approximation of
weight.
- Various
psychological,
psychosocial, and
cultural factors
conclude the type,
quantity, and
aptness of food
consumed.

- Calms down
peristalsis and
boosts available
energy for eating.
Helps out save
Short term objective:
After 8 hours of Nursing
Interventions, goal met
if the patient is able to
increase his appetite
to meet normal
metabolic demands.

Long term objective:
After 2 days of
continuous Nursing
interventions, goal met
if the patient is able to
demonstrate
improvement in skin
integrity and skin color,
stronger muscle tone
and sustain usual diet
necessary for weight
gain.
or by medical
conditions resulting in
inflammation or
obstruction of the
gastrointestinal tract. It
can also be affected
by the following:
gastrointestinal [GI]
malabsorption,
cancer, burns, muscle
weakness, poor
dentition, activity
intolerance, pain,
substance abuse, lack
of financial resources
to obtain nutritious
foods, depression,
boredom, trauma,
surgery, sepsis, burns.
The major goals for this
problem is to maintain
or restore optimal
nutrition status,
promote healthy
nutritional practices,
prevent complication
associated with
malnutrition and
regain specified
weight.

>Arrange diet with
patient or significant
other, suggestive of
foods from home if
suitable. Offer small,
frequent meals or
snacks of nutritionally
dense foods and
nonacidic foods and
beverages, with
preference of foods
appetizing to patient.
Persuade high-calorie
or nutritious foods, a
number of which may
be considered
appetite stimulants.
Note time of day
when appetite is finest,
and aim to serve
bigger meal at that
time.
>Encourage family to
take food from home
as fitting for
hospitalized patients.



>Give frequent mouth
care, noting secretion
precautions. Prevent
use of alcohol-
energy.
- Counting patient
in planning
provides sense of
control of
surroundings and
may improve
intake. Satisfying
cravings for non-
institutional food
may also enhance
intake.











- Patients with
specific ethnic,
religious partialities
or restrictions may
not be able to
consume hospital
foods.
- Lowers discomfort
related with
nausea or
vomiting, oral
containing
mouthwashes.



>Maintain patient on
NPO as indicated.




Edx>Advice to avoid
beverages that are
caffeinated or
carbonated.
>Persuade patient to
express feelings
concerning
recommencement of
diet.
>Persuade patient to
sit up for meals.

>Persuade small,
frequent meals with
foods high in protein
and carbohydrates.





>Persuade/help out
with fine oral hygiene;
lesions, mucosal
dryness, and
halitosis. Clean
mouth may
improve appetite.
- Resting the bowel
reduces peristalsis
and diarrhea,
preventing
malabsorption or
loss of nutrients.
- These may reduce
appetite and result
to early satiety.

- Uncertainty to eat
may be result of
fear that food will
lead to worsening
of symptoms
- Aids swallowing
and decreases risk
of aspiration.
- Makes the most of
nutrient intake
without
unnecessary
fatigue or energy
loss from eating
large meals, and
diminishes gastric
irritation.
- Reduces bacterial
growth, lessens
before and after
meals, use soft-bristled
toothbrush for gentle
brushing. Offer dilute,
alcohol-free
mouthwash if oral
mucosa is ulcerated.
potential for
infection. Particular
mouth-care
methods may be
required if tissue is
sensitive/
ulcerated/bleedin
g and pain is
severe.














IMPAIRED SKIN INTEGRITY
ASSESSMENT EXPLANATION OF THE
PROBLEM
GOAL/OBJECTIVE INTERVENTION RATIONALE EVALUATION
S> mejo atidug jay
dait na ya baka kitdi
mabayagan nga ag
imbag, tapos
permanent pay
gayam dytoy
pagruwaran ti takik

O>presence of
surgical incision on the
abdomen
>Stoma noted on the
left lower quadrant
>Presence of
colostomy bag



Impaired skin integrity
related to presence of
surgical incision in the
abdomen and
colostomy bag s/p EX
LAP and colostomy
Impaired skin integrity
was due to the clients
tissue trauma on the
surgical incision site
from his recent surgery
caused by colorectal
cancer. The skin is a
barrier to infectious
agents; however, any
break in the skin can
readily serve as a
portal of entry putting
the individual at risk for
potential infections.

(Fundamentals of
Nursing by Kozier,
et.al., 7th
edition, page 633)











Short term objective:
After 8hrs of nursing
intervention the client
will:
Demonstrate
beginning
acceptance by
viewing and touching
stoma and
participating in self
care.
Verbalize
feelings about stoma
and illness

Long term objective:
After 3days of nursing
intervention the client
will verbalize of
change in body
image, fear of
rejection or reaction of
others, and negative
feelings about body.


Dx>Assess skin color
and temperature in
surrounding surgical
incision and stoma.





>Monitor VS

>Assessed skin. Noted
color, turgor, and
sensation. Described
and measured wounds
and observed
changes
>Monitor all sights for
signs of wound
infection. E.g. unusual
redness, increase
edema, pain, and
fever.

Tx>Cleanse incision
with sterile saline
solution and peroxide
after dressing have
been removed.

- Skin should be pink
or similar to color of
surrounding skin.
Cyanosis will
indicate venous
congestion which
will lead to tissue
necrosis.

- To obtain baseline
data
- Establishes
comparative
baseline providing
opportunity for
timely intervention.

- Impedes healing.






- Prevents crust
formation which
can trap purulent
drainage and
increase size of
wound.
Short term objective:
After 8hrs of nursing
intervention goal met
if the client is able to:
Demonstrate
beginning
acceptance by
viewing and touching
stoma and
participating in self-
care.
Verbalize
feelings about stoma
and illness

Long term objective:
After 3days of nursing
intervention, goal met
if the client is able to
verbalize change in
body image, fear of
rejection or reaction
of others, and
negative feelings
about body.




































>Assist the patient to
turn to sides at least
every 2 hours.

>Administer antibiotics
as ordered.

>Assist in passive
movements(while 8hrs.
flat on bed) such as
bed turning and
passive ROM exercise
and active exercise
thereafter movements
such as bed
positioning, sitting,
standing, walking

Edx>Provide
opportunity for client
to deal with ostomy
through participation
in self-care.

>Instruct client to
avoid the wound to
come in contact with
linen or other surfaces
such as blankets,
pillows.

>Encourage the client
to increase in oral fluid
intake
- Changing position
in bed every 2
prevents pressure
ulcers.
- To prevent further
infection that might
occur.
- to promote
circulation to the
surgical site for
timely healing







- Independence in
self-care helps
improve self-
confidence and
acceptance of
situation.
- This would prevent
irritation on the
clients skin and
can also prevent
friction that may
cause pain and
bleeding.
- Adequate
hydration and
nutrition helps







>Encourage pt. to
verbalized his for any
untoward feelings
especially pain,
discomfort as well as
changes noted on
operative site

maintain the skin
turgor, moisture.
- to allow continuous
monitoring and
assessment of pt.
condition












RISK FOR INFECTION
Assessment Explanation of the
Problem
Objectives Interventions Scientific Rationale Evaluation
O>S/P: Ex-Lap and
Colostomy
>presence of medio-
lateral abdominal
incision
>Presence of stoma
connected to a
colostomy bag



A>Risk for infection
related to traumatized
tissue secondary to
Colostomy
The client is at risk for
infection due to
traumatized tissue
caused by an incision
on her abdominal
area. The incision
caused breaks to the
skin which might be an
opening for the
bacteria to enter the
clients body. If given
the chance, the
bacteria will multiply
until such time that
they outnumbered the
antibodies, therefore
will cause infection.


Reference(s): B runner &
Suddarths Textbook
of Medical-Surgical
Nursing 11th
Edition by Smeltzer. Et al.

Short term Objectives:
After 30 minutes of
nursing interventions,
the client will be able
to:
a) Verbalize
understanding
of individual
causative/ risk
factors.
b) Identify
interventions to
prevent/reduce
risk of infection.

Long term Objectives:
After 1 day of nursing
intervention, the client
will be able to:
Demonstrate proper
techniques on
cleaning the wound to
prevent infections,
lifestyle changes to
promote safe
environment for
prevention of
infection.

Dx>Observe for
localized signs of
infection at the site of
surgical incision.
>Assess and
document skin
conditions around the
incision.
>Note signs and
symptoms of sepsis.
>Monitor medication
regimen.


Tx>Maintain clean
environment


>maintain sterile
techniques in assessing
and cleaning the
incision site.

Edx>Emphasize
necessity of taking
antibiotics as directed.
>Instruct patient in
techniques to protect
the integrity of skin
such as maintaining
- To assist causative/
contributing
factors.

- To monitor any
existing signs of
infection

- For prompt
intervention
- To determine
effectiveness of
therapy.

- To prevent possible
source of infection
around the incision
site.
- For prevention of
infection



- To prevent
bacterial growth in
the incision site
- To promote faster
wound healing.


Short term Objective:
Goal met if the client
was able to:
a.) Understand the
different
causative
factors which
might cause
infection such
as improper
hygiene.
b.) Enumerate
ways on how to
prevent the
occurrence of
infection such
as proper
hygiene and
compliance to
medicines.

Long term Objective:
Goal met if:
a.) The client was
able to
demonstrate
proper
techniques by
observing
proper hand
intact and clean
dressing

>Instruct client on
proper hand hygiene.



>Emphasize
importance of
cleaning the wound
site frequently as
needed while
observing proper hand
hygiene.
>Instructed to discard
soiled dressings and
cottons to appropriate
receptacles



- To maintain
cleanliness and
prevent
contamination of
bacteria
- To prevent
contamination and
further infection




-To maintain hygienic
environment and
prevent growth of
microorganisms
and body
hygiene as
evidenced by
frequent
washing of
hands,
changing of
clothes and
disposal of
soiled dressings
to appropriate
receptacle

b.) After 3 days of
nursing
interventions,
the client
manifested no
signs of
infection













RISK FOR BLEEDING
Assessment Explanation of the
Problem
Objectives Interventions Scientific Rationale Evaluation
O>With intact binder
>With dry and intact
dressing
>With no signs of
active bleeding or
discharges noted
>With lab results of:
-Platelet count of 476
x 10
9
-Hemoglobin: 121 g/l
-Hematocrit: 0.36%
>With capillary refill of
2-3 seconds
>With pale skin and
nail beds
>With complaints of
pain
>Patient is conversant
and coherent
> Vital signs taken as
BP 110/70 mmHg,
The client is at risk for
bleeding because
client had undergone
an invasive procedure
which required the
need for disruption
and manipulation of
tissues which resulted
to blood loss. This will
now increase the
clients risk for
bleeding especially in
the immediate post-
operative state since
clients tissues are still
under the process of
regenerating and
healing.


Short term Objective:
After hours of
continuous nursing
interventions, client
will:
a. manifest an
improvement in
his hematologic
state as
manifested by
a capillary refill
of 1-2 seconds
b. maintain a dry
and intact
dressing
Long term Objective:
After 3 days of
continuous nursing
interventions, client
will:

Dx>note client report
of distress in the
operative area.
>Assess and record
vital signs

>Review Laboratory
data


>Assess circulatory
status as to:
- capillary refill
- skin color and
temperature
>Assess intactness of
dressing and binder



>Note signs of
- may indicate signs
of active bleeding

- to provide data
needed for early
intervention
- These tests provide
data that may be
indications of a
bleed.
- Changes in these
signs may be
indicative of blood
loss

- To note for other
complications that
may arise like
bleeding on the
operative site.
- To prevent further
Short term Objective:
Goal met. client was
able to:
- manifest an
improvement in her
hematologic state
as manifested by a
capillary refill of 1-2
seconds
- maintain a dry and
intact dressing
Long term Objective:
Goal met. Client was
able to:
- not manifest any
signs of active
bleeding
- achieve and
maintain an
improved
hematologic state
temp 36.1 oC, RR
20cpm, PR 71 bpm.


A>Risk for bleeding
related to traumatized
tissue secondary to
EX-LAP and Colostomy
a. not manifest
any signs of
active bleeding
b. achieve and
maintain an
improved
hematologic
state as
manifested by
a capillary refill
of <2secs and
pinkish skin and
nail beds
bleeding



Tx >Administered anti-
hemorrhagic
medications as
ordered by the
physician (INOTE
NALANG NATIN DITO
UNG
ANTIHEMORRHAGIC
DRUG NYA NA
BINIGAY MERON BA??)
>Administered iron
supplement as
ordered
>Offer fluids and
Vitamin C rich foods



Edx>Encourage to
comply with
medications

>Instruct to report signs
of active bleeding

>Encourage to
increase fluid intake
eat Vitamin C rich
foods
and more active
bleeding


- To prevent
bleeding and
promote blood
clotting






- To produce RBC
and prevent iron
deficiency
- For hydration,
promote wound
healing and
reduce possibility of
bleeding
- To hasten wound
healing and
reduce probable
complications
- To provide quick
intervention to
prevent further
bleeding
- For hydration,
promote wound
healing and
reduce possibility of
as manifested by a
capillary refill of
<2secs and pinkish
skin and nail beds
bleeding