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Nursing Assessment

Subjective cues:
"First time kong
maoperahan kaya hindi ko
alam ano ba dapat gawin
dito sa bahah" as
verbalized
Objective cues: N/A
Nursing diagnosis:
Knowledge deficit related
to unfamiliarity with
informational resources

Objective of care
> Within 8 hours of
nursing intervention, the
Pt. will
a) verbalize
understanding of the
disease process and
potential complications
b) verbalize
understanding about
proper way of hand
washing and wound
dressing
c) verbalize
understanding about
activity restrictions and
diet modification

Nursing Interventions

Rationale

Implementation

-identify symptoms
requiring medical
evaluation ( increasing
pain, erythematic or edema
on the wound and etc)

-prompt intervention
reduces the risk of serious
complications

-health teaching done about


the disease process and
potential complications

-discuss care of incision,


include g dressing changes,
bathing restrictions, and
return to physician for
suture and staple removal.

-understanding promotes
cooperation with
therapeutic regimen,
enhancing healing and
recovery process

-discussed about proper hand


washing and wound dressing
to the patient and significant
others

-review post op activity


restrictions and increase of
protein and Vit. C in the
diet

-provides information for


faster wound healing and to
prevent complications on
the surgical site

-instructed patient about


physical activity restrictions
such as driving, exercise and
lifting. Encouraged to
increase intake of protein and
Vit. C

-encourage the pt to cough,


breathe deeply and turn
frequently

-to prevent pulmonary


complication

-advised pt to cough, breathe


deeply and turn frequently

Evaluation
Patient verbalized
understanding about the
health teaching done to the
patient which includes
teaching about the disease
process and potential
complications, proper way
of hand washing and
wound dressing, activity
restrictions and diet
modification

Nursing Assessment
Objective cues
:> v/s taken as follows:
T= 37.0 C
PR= 81 bpm
RR= 23 breaths/min
BP= 140/90 mmHg
> S/P appendectomy
> with dry and intact
dressing on RLQ of
abdomen
Nursing diagnosis:
Risk for infection r/t
tissue trauma

Objective of care

Nursing Interventions

Within 8 hours of nursing


intervention, the Pt. and
SOs will verbalize ways
in preventing infection/
contamination,
specifically proper hand
washing, and proper
wound care.

- Monitor v/s and record.

Rationale

Implementation

-Elevation in rates may


signal infection.
- To provide baseline data
for comparison.

-vital signs was checked and


recorded every 2 hours
-dressing site was checked
and assessed

-Provide regular wound


dressing aseptically.

-To check for skin integrity


and identify need for
further management.

-instructed patient about the


proper way of changing
wound dressing

-Change linens and Pts


robes, as necessary.

-To prevent growth of


bacteria on linens and
robes.

-advised to change linens and


clothes when soiled.

- Encourage Pt. to verbalize


any changes noted on
operative site such as
redness, swelling, and
unusual/odorous drainage
on operative site.

-To allow continuous


monitoring and assessment
of Pt. for signs of infection.

-advised patient to report any


signs of infection on the
operative site

-Instruct Pt. and SOs to


refrain from
touching/scratching
operative site.
-Instruct Pt and SOs to
immediately report when
dressings are soaked.

-To prevent contamination


of operative site.

-instructed to avoid
scratching and touching the
operative site

-To prevent growth of MOs


on dressings that may cause
contamination of operative
site.

-instructed to report to NOD


when dressing are easily
soaked with blood.

-Assess operative site for


signs of infection.

- To emphasize importance
of aseptic techniques in
preventing
infection/contamination of
operative site.

Evaluation
-The Pt. and SOs verbalized
ways in preventing
infection/ contamination,
specifically proper hand
washing, and proper wound
care.

- Demonstrate to Pt. and


SOs the proper way of
giving wound care with
emphasis on proper hand
washing.
- Inform Pt. and SOs of the
importance of following the
prescribed drug regimen.
-Advise Pt. to engage in
early ambulation and have
his SOs assist him in such
activities.

- To prevent growth of
MOs especially on
operative site.
-To promote circulation at
operative site for timely
healing

-Health teaching done about


aseptic techniques wound
dressing changes and hand
washing.
-advised to take home
medications as prescribed

-advised patient to ambulate


early so that normal
functioning will return

Nursing Assessment

Objective of care

Nursing Interventions

Rationale

Subjective cues:
Masakit dito sa baba,
while pointing at RLQ of
abdomen.
> rated pain as 6 on a
scale of 10, where 1 as the
lowest and 10 as the
highest.
> reported that pain
occurs every time Pt.
moves or is moved

> Within 8 hours of


nursing intervention, the
Pt. will manifest ability to
cope with incompletely
relieved pain as
evidenced by:
a.) verbalization of
decrease in pain from
6/10 to 2/10

> Monitor v/s and record.

> Elevation in rates suggest


increased pain intensity and
frequency.
> Elevation in intensity and
frequency may indicate a
worsening condition.

-Vital signs monitored every


2 hours

> Assess surgical site for


swelling, redness, or loose
sutures.

> Swelling, redness, and


loose sutures may
contribute to the pain felt
by the Pt, and are indicative
of further management.

-surgical dressing site


inspected every 2 hours for
any changes and signs of
infection

b.) engagement in
diversional activities such
as socialization, watching
TV game shows, and
listening to mellow music

> Provide Pt. with


diversional activities such
as socialization and
watching TV game shows.
> Promote adequate rest
periods by temporarily
limiting activity.

> To help Pt. divert his


attention to other matters
other than the pain felt.

-Advised pt to engage in
diversional activities such as
listening to music and reading
books

Objective cues:
> S/P appendectomy
> with surgical incision
on RLQ of abdomen
> facial grimacing upon
movement
> guarding behavior over
surgical site
Nursing diagnostics: Acute
pain r/t skin/tissue trauma

> Assess pain


characteristics including
location, intensity, and
frequency.

Implementation

-Pain assessed for its


characteristics

Evaluation
> The Pt. manifested ability
to cope with incompletely
relieved pain as evidenced
by:
a.) verbalization of decrease
in pain from 6/10 to 2/10
b.) engagement in
diversional activities such
as socialization, watching
TV game shows, and
listening to mellow music