Assessment Nursing Scientific OBJECTIVES NURSING RATIONALE EXPECTED

Diagnosis Explanation INTERVENTIONS OUTCOME

S: Ø Anxiety r/t Because of Short Term: >assess the clients >for baseline data Short Term:
procedure and knowledge deficit, After 1 hour of NI, level of anxiety by After 1 hour of NI,
O: Patient outcome the client may the pt. will be able listening and observing the pt. shall be able
manifests: show anxiety to understand the to understand the
because of procedure and >acknowledge anxiety >to identify feelings procedure and show
>irritability unfamiliarity and show signs of or fear signs of comfort
outcome of the comfort
>poor eye procedure >provide accurate Long Term:
contact Long Term: information about the>helps client identify
situation what is reality based After 5 hours of NI,
>focus on self After 5 hours of NI, the pt. shall show
the pt. will show >stay with the patient >to make him/her decreased or no
>increased decreased or no feel that he is not manifestations of
tension manifestations of alone anxiety as
anxiety as evidenced by calmly
>increased PR, evidenced by >note defense >may interfere with discussing his or her
RR calmly discussing mechanism being used the client ability to apprehension and
his or her cope ventilating feeling
>impaired apprehension and regarding the
attention ventilating feeling procedure and
regarding the >give sedatives or diagnosis.
>urinary urgency procedure and report to the health >to allay anxiety
diagnosis. team of the client’s
>perspiration anxiety
Assessment Nursing Scientific OBJECTIVES NURSING RATIONALE EXPECTED
Diagnosis Explanation INTERVENTIONS OUTCOME
S: Ø Ineffective Anesthesia Short term: -Assess rate and -Provides baseline Short term:
breathing pattern artificially induces After 4hours of NI, depth of respiration data Pt shall demonstrate
O: >Shortness of r/t anesthetic a state of partial the pt will absence of
breath drugs secondary or total loss of demonstrate -Auscultate lung -The base of the symptoms of
to surgical sensation. absence of sounds at least every lungs are at least respiratory distress
>difficulty of operation Anesthetic agents symptoms of 4 hours for the first 48 likely to be
breathing affect the different respiratory distress hours postoperatively ventilated Long term:
systems of the therefore lung
>nasal flaring body, including Long term: After 3 sounds may be patient shall have
the respiratory days of NI, the distinguished over demonstrated
> chest retractions system. patient will the bases behaviors that may
Anesthesia demonstrate prevent the
:>tachycardia interferes with the behaviors that may -Encourage or assist -These actions formation of retained
normal movement prevent the formation patient to turn side to mobilize secretions in the
>respiratory of mucus up and of retained secretions side every 2 hours secretions lungs
grunting out of the in the lungs
bronchial tree -Encourage the patient -Deep breathing
>use of accessory causing pooling of to do deep breathing keeps the alveoli
muscles for secretions. A exercises a minimum from collapsing
breathing major of 10 times everyday
complication of
surgery may -Encourage coughing
include aspiration every hour -This cleans the
of the retained bronchial tree of
secretions secretions

-Encourage -Breathing
ambulation as effectiveness and
tolerated mobilization of
secretions are
enhanced by
position change
and an upright
position
 ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED
DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
S: Ø Short Term: >assess the degree of >for comparison Short Term:
Self care deficit r/t For client’s deficit and baseline data
O: pt may mobility musculoskeletal After 4 hours of NI, patient will
manifest: impairment trauma, further patient will >assist patient in self- >for prevention of demonstrate
movements and demonstrate care like the use of straining understanding of
>increased induce further understanding of bed bath acceptance of
dependence for injury. Patients acceptance of situation and the
self- care after ORIF, situation and the >reinforce use of need for assistance.
movement without need for assistance. assistive devices with >to assist patient
>poor hygiene assistance can collaboration with the in doing self- care Long Term:
induce alteration Long Term: therapist acitivites
>use of assisted in the fixation patient will
devices in moving plates and can After 8 months of NI, >educate patient and >to empower the demonstrate pre-
alter alignment patient will SO for importance of patient and SO injury dependence in
>hostility and fixation of the demonstrate pre- hygiene meeting self care
bones. Activities injury dependence in needs
>irritable like self- care can meeting self care >provide positive
be compromised needs reinforcement in client > to empower the
thus efforts patient
compromising the
patients hygiene.