Professional Documents
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HEALTH HISTORY:
Admission chief complain and history of present illness:
Male patient 27 year old admitted to surgical ward in basma hospital from clinic . patient work in store and before three days ago patient was carry a heavy boxes ,when he carry boxes he felt a sharp and sudden pain in inguinal area this lead to fall down the boxes .then when patient go to his home he felt this pain again when he carry television this lead patient to go to doctor yesterday then doctor was admit patient to hospital as case of right inguinal hernia and decide surgical to repair hernia .
PHYSICAL EXAMINATION:
0
0Pulse rate: 68 B/M
General appearance:
Temperature: 37.2 c 1B.P: 125/80 R.R :16 /M weight : 75kg
2height : 172cm
3Pallor, fatigued and extremely ill 4patient oriented to time place and persons
1Respiratory System:
0 Respiratory rate: 15 Breath per minute
1 Respiratory rhythm: regular 2 No wheezing and no crackles 3 dry cough .no sputum
9Diagnostic test :
Num 1 5 6 8 9 10 11 Name Glucose WBC RBC PLT Na Ca K Range 5 mmol/l 9.6 5.7 249 144 2.4 4.2 Normal range 4.2-6.4 mmol/L 4-11*10^3/m 4.5-6*10^6m 150-450*10M 135-148meq/l 2-2.6mmol/l 3.-5.3meq/l Nursing note Normal normal Normal Normal Normal Normal Normal
Medication
Objective data:
0Pulse rate: 68 B/M Temperature: 37.2c
Respiratory rhythm: regular breathing , conscious , Low level of knowledge about disease . patient walk with assistance
Nursing Diagnoses :
Nursing Diagnoses 1:
Pain related to surgical procedure as manifested by patient verbalization . Planning : Goal : Relieving Pain Postoperatively Ex. outcome : patient well verbalize pain decreased from 6 to 3 on pain scale.
Nursing Interventions :
Have the patient splint the incision site with hand or pillow when
coughing to lessen pain and protect site from increased intraabdominal pressure. Splinting and proper positing reduce the stress on the incision area.
Keep bedding clean, dry, and free of wrinkles and debris. Provide therapeutic environmentproper temperature and humidity,
ventilation, visitors. Put patient in comfort position to decrease pressure on surgical incision Explaining pain relief methods, such as Breathing exercises, heat application, and progressive relaxation because Breathing exercises and relaxation techniques decrease oxygen consumption, respiratory rate, heart rate, and muscle tension, which interrupt the cycle of pain anxietymuscle tension
Evaluation :
Goal met . patient now in general condition free from verbalization of pain and he said the scale of pain now is 3 from 10
Nursing Diagnoses 2 : Activity Intolerance related to limited mobility and weakness secondary to surgical incision and pain as manifested by patient verbalization and my observation .
Planning : Goal : increasing Activity Tolerance Ex. outcome : patient will be able to do daily activity without assistance
Nursing Interventions :
Encourage progress in the client activity level during my shift by: Allow the client legs to dangle first; support him from the side because Dangling the legs helps minimize orthostatic hypotension. Increase the client time out of bed by 15 minutes each time. Allow him to set a comfortable rate of ambulation, to prevent overexertion. Encourage the client to increase activity when pain is at a minimum or after pain relief measures take effect.
Take vital signs before activity, Repeat vital sign assessment after activity, and Assess for abnormal responses to increased activity. Because the Activity tolerance depends on the client
Nursing Diagnoses 3 : Impaired Skin Integrity related to invasive procedure as manifested by surgical incision . Planning : Goal : Minimizing Complications of Skin Impairment Ex. outcome : patient will be free from impairment skin integrity Nursing Interventions : Perform hand washing before and after contact with patient to prevent contamination . Inspect dressings routinely and change it if necessary Record amount and type of wound drainage
Nursing Diagnoses 4 : Knowledge deficit about disease and about wound care Planning : Goal : Educating the Patient Ex. outcome : patient will have good knowledge about disease and about wound care Nursing Interventions : Encourage questions to answer about illness . Describe illness and relate symptom of hernia . Answer questions honestly and completely at appropriate level . Teach patient how to care wound and how to promote healing Explain all procedure and treatment and the rational for them .
Teach patient about wound care and abut early sings of infection . Evaluation : Goal met Patient have good information about disease . all question has been answered .
patient now have good information about wound care Nursing Diagnoses 5 : Risk for Infection related to surgical incision Planning : Goal : Preventing Infection
Ex. outcome : patient will be free from sign and symptom of infection during my shift .Nursing Interventions :
Check dressing for drainage and incision for redness and swelling. Monitor for other signs/symptoms of infection: fever, chills, malaise,
diaphoresis. Administer antibiotics as order Evaluation : Goal met : no signs or symptoms of infection on patient or around surgical incision during my shift
Hani alzo3bi