NCP (PRE-OPERATIVE)

NURSING DIAGNOSIS NURSING

ASSESSMENT PLANNING RATIONALE EVALUATION
INTERVENTION
Subjective Cues: Deficient knowledge After 1 hour of nursing  Determine client’s ability,  This Facilitates planning of After 1 hour of nursing
“Ano nga po ulit yung related to unfamiliarity intervention, the patient readiness, barriers to preoperative teaching intervention, the patient:
learning and level of program, identifies content
gagawin sa akin?” as with procedure as must: understanding. needs.  Participated in learning
verbalized by the patient evidenced by request of  Participate in learning process and treatment
clarification regarding the process and treatment  Provides knowledge base regimen as evidenced
procedure regimen.  Review specific pathology from which patient can make patients by active
and anticipated surgical informed therapy choices and
listening and asking for
procedure. Verify that consent for procedure, and
Objective Cues:  Verbalize understanding appropriate consent has been presents opportunity to more information
 Patient exhibit of condition, signed. clarify misconceptions. during health teaching.
apathetic behavior as perioperative process
observed by nurse and treatment.  Objectives and goals must  Verbalized
meet learner’s needs and not
 State objectives and the instructor/nurse. understanding of
 Patient exhibits  Correctly perform outcomes to be achieved condition, perioperative
restlessness prior to necessary procedures clearly in learner’s terms  This reinforces learning process and treatment as
procedure as observed and explain reasons for which is specifically evidenced by patient’s
by the nurse  Use appropriate resource designed to facilitate verbalization of the
the actions teaching materials patient’s learning.
purpose of the operation
 Patient state concerns  Pre-operative procedures and rationale for pre-
regarding the  Explain pre-operative helps reduce the possibility operative procedures
procedure and request procedures: NPO, Skin of postoperative and preparations.
preparation, holding of complications and promotes
for further information medications, prophylaxis a rapid return to normal body
and anesthesia medications function.  Correctly performed
and state the reason for this necessary procedures
procedure.  Relieves stress and and explained reasons
miscommunication and for the actions as
 Inform patient or SO about prevent doubt about patient’s
itinerary, physician and SO wellbeing. evidenced by complying
communications. with NPO status and
 Enhances patient’s skin preparations.
 Explain about possible understanding or control and
intraoperative and post- can relieve stress related to
operative procedures and the unknown or unexpected.
expectations.
 To determine client’s
learning and validate
information.
 Provide for feedback and
evaluation of learning and
assist client for further
questions
 NCP (POST-OPERATIVE)

PLANNING NURSING
ASSESSMENT NURSING DIAGNOSIS RATIONALE EVALUATION
INTERVENTION
Subjective Cues: Alteration in Comfort: After 5 hours of nursing  Monitor skin color and  Which are usually altered After 5 hours of nursing
“Sumasakit ang tahi ko. Acute Pain related to intervention, the client temperature and vital in acute pain. intervention, the client
Di ako makagalaw ng post-surgical procedure. will: signs. was able to:
maayos dahil sa sakit.”  Report pain is relieved
as verbalized by the or controlled.  Perform pain assessment  To demonstrate  Verbalized pain is
each time pain occurs. improvement in status and
patient relieved and controlled.
Document and investigate to identify worsening of
changes from previous underlying condition.
reports and evaluate  Pain scale of 2/10.
results of pain
Objective Cues: interventions.
 (+) Pain on incision
site  Perform wound cleaning  To diminish the irritability
and dressing. of the patient.
 Pain scale of 5/10
 Encourage  To evaluate coping
 (+) facial grimace
verbalization of abilities and to identify
feelings about the areas of additional
 Restlessness pain such us concern.
concern about
 Irritability tolerating pain,
anxiety, pessimistic
thoughts

 Administer analgesics, as  To maintain “acceptable”

indicated, to maximum level of pain. Notify
dosage, as needed. physician if regimen is
inadequate to meet pain
 Provide comfort measures control goal.
(e.g., touch, repositioning,
use of heat or cold packs,
nurse’s presence), quiet  To promote
environment, and calm nonpharmacological pain
activities management.