ACTUAL NURSING CARE MANAGEMENT

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ngol-ngolakongtinahian as verbalized by patient Cold clammy hands Guarding Moderate pain related to surgical incision Short Term: At the end of 30mins 1hour, the client will be able to verbalize reduce tolerable degree of pain up to relieve pain. INDEPENDENT: 1. Applied cold compress to affected area Promote vasoconstriction thus helps relieve pain 2. Encouraged to listen to music To divert attention from pain

3. Instructed to avoid switching from different position To avoid putting pressure on affected area 4. Encouraged adequate rest periods To prevent fatigue 5. Encouraged early ambulation To promote wound healing

After the end of 30mins 1hour, the client had verbalized reduce tolerable degree of pain up to relieved pain.

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initakongpaminawsasulodsaakonglawas as verbalized by patient Actual temperature: 37.9oC Weak Hyperthermia related to slightly elevated body temperature Short Term: At the end of 30mins, the clients body temperature will be able to decrease to normal range of 37.0-37.5oC INDEPENDENT: 1. Monitored vital signs As baseline data 2. Performed tepid sponge bath To release heat via evaporation

3. Advised to use loose garments To avoid vasoconstriction and avoid heat 4. Opened windows For proper ventilation 5. Offered cold drinks Release heat via conduction

At the end of 30mins, the clients body temperature was decreased to normal range of 37.0-37.5oC

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Surgical incision Elevated vital signs T : 37.9oC P : R : BP:

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Risk for infection related to post operative wound Short Term: At the end of 30mins, the clients will be able to identify preventive measures to decrease the risk of infection. INDEPENDENT: 1. Taught proper wound care To reduce risk for infection 2. Instructed to frequently change dressing Moisture can harbor microorganisms

3. Encouraged early ambulation To promote wound healing 4. Instructed to check dressing for any unusualities and discharges To assess the degree of care DEPENDENT: 5. Administer antibiotics

After the end of 30mins, the clients was able to understand preventive measures to decrease the risk of infection.