NRS C007-09-0 LORMA MEDICAL CENTER Carlatan, San Fernando City, La Union NURSING CARE LAN Name of Patient:

AMOYEN, APRIL MACUSI Date of A mission: !"#"$#%!"& !':!!:!! AM Dia*nosis: ASSESSMENT S- . /in i +a masya o ma*a0in* an* s(*at 1o2 as 3e)4a0i5e 4y the +atient O- S#P A++en ecto my -6ith s()*ica0 incision at )i*ht 0o6e) a4 omina0 a)ea NURSING DIAGNOSIS Im+ai)e S1in Inte*)ity )e0ate to s1in#tiss(e t)a(ma as e3i ence 4y the s()*ica0 incision at )i*ht 0o6e) a4 omina0 a)ea (e to a++en ectomy LAN Afte) the 7 ho()s of n()sin* inte)3ention the c0ient 6i00 4e a40e to manifest the fo00o6in*: a.8 intact s(t()es 4.8 )y an intact 6o(n )essin* c.8 +a)tici+ation in +assi3e ROM e9e)cises NURSING INTER!ENTION -Assess o+e)ati3e site fo) )e ness, s6e00in*, 0oose s(t()es, o) soa1e )essin* Physician: DR GUNDRAN, NELSON, M. S()*e)y: Eme)*ency A++en ectomy Date of s()*e)y: !"#"$#%!"& ,:,! +m RATIONALE -to chec1 s1in inte*)ity, monito) +)o*)ess of hea0in* an i entify nee fo) f()the) - Se)3e as 4ase0ine ata -to +)omote ci)c(0ation to the s()*ica0 site fo) time0y hea0in* E!ALUATION Afte) the se)ies of n()sin* inte)3ention the *oa0 has 4een met as manifeste 4y the fo00o6in*: a.8 intact s(t()es 4.8 )y an intact 6o(n )essin* c.8 +a)tici+ation in +assi3e ROM e9e)cises

-Monito) :ita0 Si*ns -Assist in +assi3e mo3ements;6hi0e 7h)s. f0at on 4e 8 s(ch as 4e t()nin* an +assi3e ROM e9e)cise an acti3e e9e)cise the)eafte) mo3ements s(ch as 4e +osition, sittin*, stan in*, 6a01in* -Enco()a*e +t to 3e)4a0i5e his fo) any (nto6a) fee0in*s es+ecia00y +ain, iscomfo)t as 6e00 as chan*es note on o+e)ati3e site

-to a00o6 contin(o(s monito)in* an assessment of +t. con ition

-to +)omote ci)c(0ation to the s()*ica0 site fo) time0y hea0in*

<LORES. MIC/AEL C/ES=ER M. NURSE ON DUT"