Assessment

Diagnosi s

Planning

Interventions Independent:

Rationales

Evaluation

Subjective: Naoperahanakosatagiliranbandangkanan , as verbalized by the client.

Objectives: -disruption of skin surface(Epidermis) -disruption of skin layer (Dermis) -Appearance -kind of suture -Inflammation -types of drain -amount of secretions, color, consistency and odor.

Impaired skin integrity related to surgical incision secondar y to

Long term: After 3-4 days of nursing interventions, the client will be able to achieve progressive healing of surgical wounds without complications. - Discuss importance of early detection of skin damages or complication.

Long term:

Short term: After 1 hr. of nursing interventions, the client will be able to:

- Instruct proper hygiene and selfcare as well in her surroundings.

- Express willingness to participate in the prevention of further complication.

-Instruct to use appropriate barrier/ dressing.

-Proper hygiene will prevent infection, complication and occurrence of any disease. -to protect the wound and/ or surrounding tissue

After 3-4 days of nursing interventions, the client achieved progressive healing of surgical wounds without complications .

-Change surgical or other wound dressing as indicated.

Short term: After 30 mins. of nursing

Verbalizeunderstandin g about methods that promotes healing. -Provide optimum nutrition by increasing amounts of calories, proteins, Vitamin A and C.

- Demonstrate proper hygiene and maintenance of the skin.

-moistened dressings are favourable site for microorganis m to culture.

interventions, the client was able to:

-Encourage early ambulation, regular exercise.

-Promote healing and general good health

- Expressed willingness to participate in the prevention of further complication.

-Periodically measure wound and observe for complications such as infection or dehiscence.

-to promote circulation improve strength and reduce risks associated with immobility

- Verbalized understanding about methods that promotes healing.

-Support surgical

Demonstrated proper hygiene and maintenance of the skin.

incision (E.g. Splinting when coughing)

-to monitor progress wound healing

-Encourage client to adhere to medical regimen and follow-up care. -to prevent the occurrence of dehiscence and evisceration

Dependent: -Administer prescribed medication such as_____________ _

-to monitor healing process and provide for timely intervention as needed

-Vitamin C promotes wound healing and diuretics decreases renal vascular resistance and may increase renal blood flow

Assessment

Diagnosi s

Planning

Intervention s Independent:

Rationales

Evaluation

Subjective: Nahihirapanakonggawinangmgabagaykagayangpagpapalitng

Self-care Long term: deficit After 2-4 due to

Long term: -Encourage -Enhances

damit at pagpuntasabanyo, as verbalized by the client.

Objectives: -weakness -need assistance of significant others -Guarding behaviour

presence of surgical incision

days of nursing interventions , the client will be able to increase strength and perform self-care activity within level of own ability.

participation in self-care, occupational / diversion/ recreational activities.

self-concept and selfindependenc e

-Identify energy conserving technique for ADLs

After 2-4 days of nursing interventions , the clients strength increased and performed self-care -limits activities fatigue, within level maximizes of own participation ability

Short term:

-Assist client in leaving After 30 and mins. of demonstratio nursing interventions n appropriate , the client will be able safety measures to: such as ideal toilet practice for -verbalize postwillingness operative and

-to prevent injuries, pain or discomfort

Short term: After 30 mins. of nursing interventions , the client was able to:

--verbalized willingness and

demonstrate participation in activities

patient.

-Discuss -to sustain client motivation -verbalize information understandin that provides g of evidence of situations daily/ and weekly individual progress treatment regimen and safety -Encourage -promotes measures adequate wellbeing intake of and fluid/ maximizes nutritious energy foods production

demonstrate d participation in activities

-verbalized understandin g of situations and individual treatment regimen and safety measures

Dependent:

-administer

to alleviate if pain is present.

-to permit maximal effort/ involvement in activity

Assessment

Diagnosis

Planning

Interventions Independent:

Rationales

Evaluation

Subjective: Medyomasakit pa angtahikokapagnagsasalit a at gumagalawako., as verbalized by the client.

Acute pain related to postoperative abdominal incision

Long term: After 3-4 days of nursing interventions, the client will be able to state that degree of pain is tolerable -Discuss impact of -to maximize pain on level of lifestyle/independence functioning and ways.

Long term:

Objectives: -Degree of pain: 3(3 out of 10, 10 as the highest) -Discomfort -Guarding behaviour -weakness Short term: After 30 mins. of nursing interventions, the client will be able to:

-Vital signs were monitored every 1 hour until stable.

-alterations from normal may be signs of infection.

After 2-4 days of nursing interventions, the clients strength increased and performed selfcare activities within level of own ability

-provide quiet environment, calm activities.

Short term: -to provide comfort After 30 mins. of nursing interventions, the client was able to:

-verbalize understanding about the methods that provide relief.

-Instruct in/ encourage use of relaxation exercise

-Demonstrate use of relaxation skills and divisional activities as indicated for individual situations.

such as focused breathing and diaphragmatic breathing.

-to assist in muscle and generalized relaxation.

--verbalized willingness and demonstrated participation in activities

-Encourage adequate rest periods to prevent fatigue and this promotes healing by reducing basal metabolic rate and allowing oxygen and -to be utilized for nutrients. tissue growth, healing and regeneration.

-verbalized understanding of situations and individual treatment regimen and safety measures

Dependent:

-administer analgesic/pain reliever and antibiotics as indicated to maximal dosage as needed to

maintain acceptable level of pain. -antibiotics are used to treat and infections caused by susceptible pathogens in skin structure infections.

PROBLEM PRIORITIZATION DATE IDENTIFIED CUES NURSING DIAGNOSIS JUSTIFICATION

This diagnosis has to be

Subjective: Medyomasakit pa angtahikokapagnagsasalita at gumagalawako., as verbalized by the client.

Acute pain related to post-operative abdominal incision

Objectives: -Degree of pain: 3(3 out of 10, 10 as the highest) -Discomfort -Guarding behaviour -weakness

the first prioritized problem because this is an actual problem and based on Maslows Hierarchy of Needs, physiological needs must be prioritized first. Acute pain is a physiological dimension and pain causes changes to the clients homeostasis. it is the 5th vital sign. Pain can affect the treatment and cooperation of the patient. It also limits his movements as stated by the client, thus slowing down his recovery.

Subjective: Naoperahanakosatagiliransakanan, as verbalized by the client.

Impaired skin integrity related to surgical incision.

This is also an actual problem. The client has impairment in the integrity of her skin due to surgical procedure done. Interventions needed to address this

Objectives: -disruption of skin surface (Epidermis) -disruption of skin layer (Dermis) -Appearance -kind of suture -Inflammation -types of drain -amount of secretions, color, consistency and odor.

problem to prevent further impairment to the clients current condition.

Subjective:

Self-care deficit due to presence of Nahihirapanakonggawinangmgabagaykagayangpagpapalitngdamit surgical incision. at pagpuntasabanyo, as verbalized by the client.

Objectives: -weakness -need assistance of significant others -Guarding behaviour

Based on Maslows hierarchy of needs, Hygiene including bathing, proper dressing, grooming, oral care and other ADLs is in the physiological needs. Thus, this diagnosis is the third to be prioritized and give appropriate interventions in order to reduce discomfort of the skin due to

presence of pain, impairment and prevent the occurrence of any infection.

Subjective: Nagpapacheck-up lngakosa doctor kapag may masakitnataglaga at kapagpansinkongnababagonapagtatrabahoko, as verbalized by the client.

Knowledge Deficit

Objectives: -asking questions related to the disease -inaccurate follow of instructions -inappropriate or exaggerated behaviours.

This is the 4thprioritized nursing diagnoses because this could hinder the process of recovery and healing of the wounds. This also could contribute to the disease process if not resolve.

Subjective:

Risk for infection related to: -surgical incision -presence of

Objectives:

Infection is invasion and multiplication of pathogenic microorganisms in a bodily part or tissue,

-presence of surgical incision

drains -poor hygiene

which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms. The fact that the patient has incision site would make him more vulnerable in developing infection. This is the 5thprioritized nursing diagnosis because according to the rule risk problem should prioritized least, because actual problem should be solve first.