PREOPERATIVE NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Anxiety related to After 4 hours of  Monitor vital  To identify Goal met as
“Natatakot akong actual/ perceived nursing signs. physical evidenced by
magpaopera!” as threat to death as intervention before responses patient appear
verbalized by the patient. manifested by the settled associated relaxed and report
increased tension. operation, the with both anxiety is reduced
OBJECTIVE: patient will appear medical and to a manageable
 Restlessness relaxed and report emotional level as
 Narrowed focus anxiety is reduced conditions. manifested by
 Voice quivering to a manageable  Observe  This can decreased tension
 Hand tremors level as manifested behaviors. point to the after 4 hours of
 Facial flushing by decreased client’s level nursing
 Observed: tension. of anxiety. intervention.
 Feelings of  Be aware of  Interferes the
adequacy defense ability to deal
 apprehensi mechanisms with
on being used. problem.
 Provide accurate  Helps the
information client to
about the identify what
situation. is reality
 Establish a based.
therapeutic  To avoid a
relationship, contagious
conveying effect/
empathy and transmission
unconditional of anxiety.
positive reward.
 INTRAOPERATIVE NCP
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Tachypnea Ineffective breathing The patient will  Administer  For Goal met as
 Decreased pattern related to establish a normal/ oxygen at management manifested by
respiratory decreased lung effective respiratory lowest of underlying patient established a
depth/ vital expansion (pain and pattern as evidenced concentration pulmonary normal/ effective
capacity muscle weakness) by absence of indicated and condition, respiratory pattern as
 Decreased secondary to surgery cyanosis and other prescribed respiratory evidenced by
inspiratory/ as manifested by signs and symptoms respiratory distress, or absence of cyanosis
expiratory decreased of hypoxia after the medications. cyanosis. and other signs and
pressure respiratory depth/ surgery. symptoms of hypoxia
 Decreased vital capacity.  Monitor pulse  To verify after the surgery.
minute oximetry, as maintainance
ventilation indicated. /
 Cyanotic improvement
in oxygen
saturation.

 Stress  To maximize
importance of respiratory
good posture effort.
and effective
use of
accessory
muscles.
 POSTOPERATIVE NCP
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Impaired physical After 12 hours of  Observe  To note any in Goal met as
“Hindi ako mobility related to nursing movement congruencies manifested by the
masyadong pain/discomfort intervention, the when client is with reports of patient maintains
makagalaw dahil secondary to patient will unaware of abilities. position of function
masakit pa ang sugat surgical operation maintain position observation.  For position and skin integrity as
ng operasyon ko.” As as manifested by of function and  Instruct in the changes and evidenced by
verbalized by the limited range of skin integrity as use of side rails, transfers. absence of
patient. motion. evidenced by overhead contractures, foot
absence of trapeze, and drop, decubitus, and
OBJECTIVE: contractures, roller pads.  Permits maximal so forth after 12
 Limited range footdrop,  Administer effort/ hours of nursing
of motion decubitus, and so medications involvement in intervention.
 Difficulty forth. prior to activity activity.
turning as needed for
 Slowed pain relief.  Maintains
movement  Support position of
 Postural affected body function and
instability parts/joints reduce risk of
 Gait changes using pillows/ pressure ulcers.
rolls, foot
supports/ shoes,
air mattress,
water bed, and
so forth.  Promotes
 Encourage wellbeing and
adequate intake maximizes
of fluids/ energy
nutritious foods. production.