NCP- TAHBSO
Name: Ralph Raymond A. Agustin BSN-4
ASSESSMENT
Subjective:
“masakit dito banda” as Verbalized by
the patient evidenced by arm pointing
at epigastric region.
DIAGNOSIS
PLANNING
Pain related to
tissue trauma
secondary to
(TAH) Total
Abdominal
Hysterectomy.
After 8 hours
of nursing
interventions
the patient’s
pain will be
relieved.
INTERVENTION
RATIONALE
Independent:
Provide Comfort measures
Promoting relaxation
like helping patient assume
enhances coping
position of comfort. Suggest
abilities.
use of relaxation technique
and deep breathing exercises.
Objective:
Encourage early ambulation
Conscious and Coherent
Weak in Appearance
With intact and dry dressing over
the incision site.
abilities
Encourage divertional
attention that may
reading books.
help in coping
processes.
Provide adequate rest periods
With minimal vaginal discharges
Able to perform ADL with
assistance
V/S taken as follows:
T: 36.7
P: 70
R: 25
BP: 110/80
Refocuses the
activities like waching T.V. or
Facial grimace when in pain
With guarding behaviour
Enhances coping
Will help the client in
the coping process.
Assist client to learn
breathing techniques
Collaborative:
Provide for individualized
physical therapy or exercise
program that can be continued
by the client after discharge.
To assist in muscle
and generalized
relaxation
Promotes active, rather
than passive, role and
enhances sense of
control.
EVALUATION
After 8 hours
of nursing
interventions
Goal is
completely
met, pain is
relived.
NCP-HYSTERECTOMY
NAME: RALPH RAYMOND A. AGUSTIN BSN-4
ASSESSMENT
“Nahihirapan akong
umihi” as verbalized
by the patient.
Objective:
V/S taken as
follows:
T: 36.7
P: 70
R: 25
BP: 110/80
Urine output- <500 ml
DIAGNOSIS
Urinary
retention
related to
presence of
local tissue
edema
evidenced by
bladder
distention
PLANNING
Patient will
empty
bladder
regularly
and
completely
INTERVENTION
Independent
1. Note voiding pattern
and monitor urinary
output.
2. palpate bladder.
investigate reports of
discomfort, fullness,
inability to void.
RATIONALE
1. May indicate urinary retention if
voiding frequently in
small/insufficient amounts (<100
mL).
2. Perception of bladder fullness,
distension of bladder above
symphysis pubis indicates urinary
retention.
3. Provide routine
voiding measures,
e.g., privacy, normal
position, running
water in sink, pouring
warm water over
perineum.
3. Promotes relaxation of perineal
muscles and may facilitate voiding
efforts.
4. Provide/encourage
good perianal
cleansing and catheter
care (when present).
5. Urinary retention, vaginal
drainage, and possible presence of
intermittent/indwelling catheter
increase risk of infection,especially
if patient has perineal sutures.
5. Assess urine
characteristics, noting
color, clarity, odor.
Collaborative
1. Catheterize when
indicated/per protocol
if patient is unable to
void or is
uncomfortable.
2. Decompress bladder
slowly.
4. Promotes cleanliness, reducing risk
of ascending urinary tract infection
(UTI).
1. Edema or interference with nerve
supply may cause bladder
atony/urinary retention requiring
decompression of the bladder.
Note: Indwelling urethral or
suprapubic catheter may be
inserted intraoperatively if
complications are anticipated.
2. When large amount of urine has
accumulated, rapid
bladderdecompression releases
EVALUATION
Goal was
met. Patient
has emptied
bladder
regularly
and
completely
3. Maintain patency of
indwelling catheter;
keep drainage tubing
free of kinks.
4. Check residual urine
volume after voiding
as indicated.
pressure on pelvic arteries,
promoting venous pooling.
3. Promotes free drainage of urine,
reducing risk of urinary
stasis/retention and infection.
4. May not be emptying bladder
completely; retention of urine
increases possibility for infection
and is uncomfortable/painful.
NCP – POST OP.
NAME: RALPH RAYMOND A. AGUSTIN BSN-4
ASSESSMENT
DIAGNOSIS
PLANNING
Subjective:
Patient verbalized
“masakit yung tahi dito
sa tiyan ko. Mga 5 ang
sakit niya pero kaya ko
pang tiisin. Sumasakit
lang siya pag may
kinakain ako o kaya pag
masyado akong
gumagalaw.”
Pain related to
abdominal
surgical incision
(on abdomen
with a surgical
incision of 4
inches)
manifested by
verbal report of
pain & guarding
behavior.
Goal:
After 8 hours of
nursing
intervention
patient will report
a decrease of
pain from 5 to 4
and below.
Objective cues:
Assessed pain scale,
dressing is not soaked
of bloody discharge,
guarding behavior
noted when patient
moves, facial grimace
noted
Objective:
After 4 hrs.
patient will be
able to:
- demonstrate
different
relaxation
techniques to
decrease pain
- understand a
need for rest
period after each
activity done.
INTERVENTION
Diagnostic
Assess pain scale
Monitor vital signs
Therapeutic:
-Provide a quiet
environment
- Assist patient during
activities
-Administer analgesic if
indicated
RATIONALE
-Helps to determine effectiveness of
therapy for pain
-To monitor if there are any changes
-To minimize stress that patient is
experiencing
-To minimize feeling of pain
-To provide relief through drug
interaction
Health Teaching:
- Emphasize importance
rest periods after every
activity
-Wound healing requires protein &
calories for building new cells. The
immune system depends on protein
& calories to produce antibodies.
EVALUATION
Goal:
After 8 hours of nursing
intervention patient did
not manifest signs and
symptoms of infection
during the whole
procedure & after the
procedure.
Objective:
After 4 hrs the patient
was able to recover
from surgery without
any complications.
-was able to understand
importance of wellbalanced diet.
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