Nursing Diagnosis

Cues | Nursing Diagnosis | Scientific Explanation | Objectives/Plan of Care | Nursing Interventions | Rationale | Evaluation | S> “ Hindi pa masyado magaling ang sugat ko” as verbalized by the patientO> S/P Appendectomy>with surgical incision at right lower abdominal area>with dry intact dressing on the surgical site | Impaired Skin Integrity related to skin/tissue trauma | Inflammation of the appendix↓Acute Appendicitis↓Appendectomy↓Dissection if right lower abdominal tissues↓Disruption of skin surface and destruction of skin layers↓Impaired skin/tissue integrity | Within 8 hours of nursing intervention the pt will be able to manifest the following:a.) intact suturesb.) dry and intact wound dressingc.) participation in passive ROM exercises | >Assess operative site for redness, swelling, loose sutures, or soaked dressing>Monitor Vital Signs>Assist in passive movements(while 8hrs. flat on bed) such as bed turning and passive ROM exercise and active exercise thereafter movements such as bed position, sitting, standing, walking> Support incision as in splinting when coughing and during movement>Encourage pt to verbalized his for any untoward feelings especially pain, discomfort as well as changes noted on operative site>Encourage pt to engage early ambulation and have SO’s assist him in such activities>Instruct pt and SO’s to immediately report when dressing are soaked>Instruct pt and SO’s to refrain from touching/scratching operative site>Provide regular dressing care>Administer Chlorampenicol Sodium(antibiotic) as ordered | >to check skin integrity, monitor progress of healing and identify need for further> Serve as baseline data>to promote circulation to the surgical site for timely healing>to reduce pressure on the operative site>to allow continuous monitoring and assessment of pt. condition>to promote circulation to the surgical site for timely healing>to promote circulation to the surgical site for timely healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to avoid accumulation of moisture at the operative sitewhich may lead to skin breakdown>to prevent bacteria harbor in operative site | Within 8 hours of nursing intervention the pt be able manifest the following:a.) intact suturesb.) dry and intact wound dressingc.) participation in passive ROM exercises>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation |

Cues | Nursing Diagnosis | Scientific Explanation | Objectives/Plan of Care | Nursing Interventions | Rationale | Evaluation | S>”Hindi namn ako nilalagnat” verbalized by the patientO> v/s taken as follow:BP:110/80 mmHgRR:22 cpmPR:68 bpmT: 37.0 C> S/P Appendectomy>with dry intact dressing on the surgical site | Risk for infection related to tissue trauma | Inflammation of the appendix↓Acute Appendicitis↓Appendectomy↓Tissue trauma on RLQ abdomenMay provide portal of entry for pathogens through:>unnecessary exposure of surgical site>inadequate aseptic techniques especially in wound dressing>contract with pt’s, SO’s and visitors hands or other parts↓May result to infection | Within 8 hours of nursing intervention the pt will be able verbalize ways in preventing infection/contamination specifically proper hand washing, and proper wound care as evidenced by:>maintain stable v/s>good skin integrity>absence of swelling redness and pain on operative site | >Monitor v/s and record>assess operative site for signs of infection>change linens as necessary>Provide regular dressing care>Instruct pt and SO’s to refrain from touching/scratching operative site>Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage >Encourage pt to engage early ambulation and have SO’s assist him in such activities>Administer Penicillin G Sodium(antibiotic) as ordered | >Elevation in rates may signal infection>to provide baseline data for comparison and identify need for further management>to prevent growth of microorganisms on linens and beds> to prevent unnecessary exposure and contamination of operative sitewhich may delay wound healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to allow continuous monitoring and assessment of pt. condition>to promote circulation to the surgical site for timely healing>serve as prophylactic treatment and prevent bacteria to harbor on operative site | Within 8 hours of nursing intervention the pt will be able verbalize ways in preventing infection/contamination specifically proper hand washing, and proper wound care as evidenced by:>maintain stable v/s>good skin integrity>absence of swelling redness and pain on operative site>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation |

Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago City

Cues | Nursing Diagnosis | Scientific Explanation | Objectives/Plan of Care | Nursing Interventions | Rationale | Evaluation | S> “Masakit ditto sa baba”, while pointing at RLQ of abdomen.>rated pain as 5 on a scale of 10, where 1 as the lowest and 10 as the highest>characterized pain as pricking>reported that pain occurs everytime when pt moves or movedO> v/s taken as followsT: 37.0 CRR: 21 cpmPR: 64 bpmBP: 120/70 mmHg> S/P Appendectomy>with dry intact dressing on the surgical site>with guarding behavior over the site>facial grimacing | Acute pain related to tissue damage 2nd to post appendectomy | Inflammation of the appendix↓Acute Appendicitis↓Appendectomy↓Dissection if right lower abdominal tissues↓Disruption of skin surface and destruction of skin layers↓Activation of nociceptors in dermis and tissues↓Receptors send impulses to CNS for interpretation↓Pain Perception↓Acute Pain | Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 2/10b.) engagement in diversional activities such as socialization, watching TV, and listening mellow music | >Monitor V/S and record>Assess pain characteristics including location, intensity, and frequency>Assess surgical site for swelling, redness or loose sutures>Promote adequate rest periods by temporarily limiting activity>Encourage pt to verbalize pain perception>Provide pt with diversional activities such as socialization, watching TV, and listening mellow music>Encourage SO’s to continue provision of diversional activities and a quiet environment >Administer Toradol (analgesic)as ordered | >Elevation in rates suggest increased pain intensity and frequency>Elevation in intensity and frequency may indicate worsening condition>Swelling, redness , and loose sutures may contribute to the pain felt by pt. and are indicative of further management>to lessen pain felt aggravated by movements>to allow further assessment of pain characteristics and evaluation of treatment / intervention>to help pt divert his attention to other matters than pain felt>to allow pt continue divert his attention>to relieved or lessen pain by inhibiting prostaglandin synthesis | Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 0/10b.) engagement in diversional activities such as socialization, watching TV, and listening mellow music>verbal report that pain is completely releived>absence of facial grimacing upon performance of activities such as changing position, sitting ,standing and walking> absence of guarding behavior over surgical site>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation |