Name: Patient D Age: 32 Gender: Male Diagnosis: S/P Appendectomy Nursing Assessment S:> “ 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. > characterized pain as pricking > reported that pain occurs every time Pt. moves or is moved O:> v/s taken as follows: T= 37.0 C PR= 83 bpm RR= 23 breaths/min BP= 110/70 mmHg > S/P appendectomy > with surgical incision on RLQ of abdomen > facial grimacing Explanation of the Problem Inflammation of the appendix Acute Appendicitis Appendectomy Objectives STO:> 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 b.) RR will be decreased from 23 to 19 breaths per minute, while other v/s remain within normal range c.) engagement in diversional activities such as socialization, watching TV game shows, and listening to mellow music Nursing Interventions Dx:> Monitor v/s and record. > Assess pain characteristics including location, intensity, and frequency. > Assess surgical site for swelling, redness, or loose sutures. Rationale

Date: June 28, 2008 Shift: 3-11 Ward: Private Room N3302 Evaluation > The Pt. manifested ability to cope with incompletely relieved pain as evidenced by: a.) verbalization of decrease in pain from 6/10 to 4/10 b.) decreased RR from 23 to 19 breaths per minute, while other v/s remained within normal range c.) engagement in diversional activities such as socialization, watching TV game shows, and listening to mellow music

> Elevation in rates suggest increased pain intensity and frequency. > Elevation in intensity and frequency may indicate a worsening condition. > Swelling, redness, and loose sutures may contribute to the pain felt by the Pt, and are indicative of further management. > To help Pt. divert his attention to other matters other than the pain felt. > To lessen pain felt aggravated by movements.

Dissection of right lower abdominal tissues Disruption of skin surface and destruction of skin layers Activation of

Tx: > Provide Pt. with diversional activities such as socialization and watching TV game shows. > Promote adequate rest periods by temporarily limiting

> Evaluation was not carried out due to time

upon movement > guarding behavior over surgical site A:> Acute pain r/t skin/tissue trauma

nociceptors in the dermis and tissues Receptors send impulses to CNS for interpretation Pain perception Acute Pain LTO:> Within 3 days of nursing intervention, the Pt. will manifest signs of completely relieved pain as evidenced by: > verbal report that pain is completely relieved > absence of facial grimacing upon performance of activities such as changing position, sitting, standing, and walking > absence of guarding behavior over surgical site

activity. > Administer Toradol (analgesic), as ordered. Edx:> Encourage Pt. to verbalize pain.

> To relieve or lessen pain by inhibiting prostaglandin synthesis. > To allow further assessment of pain characteristics and evaluation of treatment/ interventions. > To allow Pt. to continue to divert his attention to other matters other than felt pain.

constraints. Pt. was endorsed to succeeding members of the health team for further management and evaluation.

> Encourage SOs to continue provision of diversional activities and a quiet environment.

Name: Patient D Age: 32 Gender: Male Diagnosis: S/P Appendectomy Nursing Assessment S:> “Hindi pa masyadong magaling tong sugat ko” as verbalized by the patient O: > S/P appendectomy > with surgical incision at right lower abdominal area > with dry and intact dressing on the surgical site A:> Impaired skin/tissue integrity related to skin/tissue trauma Explanation of the Problem Inflammation of the appendix Acute Appendicitis Appendectomy Objectives STO: > Within 8 hours of nursing intervention, the Pt. will manifest the following: a.) intact sutures b.) dry and intact wound dressing c.) participation in passive ROM exercises LTO: > Within 3 days of nursing intervention the Pt. and SOs will demonstrate: a.) proper aseptic wound care technique b.) proper supporting of incision such as splinting c.) engagement in active movements such as sitting, standing, and walking Nursing Interventions Dx: > Assess operative site for redness, swelling, loose sutures, or soaked dressings. Tx: > Provide regular wound dressing. > Assist in passive movements (while flat on bed for 8 hours) such as bed turning and passive ROM exercises, and active (thereafter) movements such as changing bed position, sitting, standing, and walking. > Support incision, as in splinting when coughing, and during movement. > Administer Zefocent (antibiotic), as Rationale

Date: June 28, 2008 Shift: 3-11 Ward: Private Room N3302 Evaluation > The patient manifested the following: a.) intact sutures b.) dry and intact wound dressing c.) participation in passive ROM exercises

Dissection of right lower abdominal tissues Disruption of skin surface and destruction of skin layers Impaired skin/tissue integrity

> To check for skin integrity, monitor progress of healing, and identify need for further management. > To avoid accumulation of moisture at the operative site that may lead to skin breakdown. > To promote circulation to the surgical site for timely healing.

> Evaluation was not carried out due to time constraints. Pt. was endorsed to succeeding members of the health team for further management and evaluation.

> To reduce pressure on the operative site. > To prevent bacteria to harbor in the operative site

ordered.

Edx:> Encourage Pt. to verbalize any untoward feelings, esp. discomfort or pain, as well as changes noted on operative site. > Instruct Pt. and SOs to refrain from touching/scratching operative site. > Instruct Pt and SOs to immediately report when dressings are soaked. > Demonstrate to Pt. and SOs the proper way of giving wound care with emphasis on proper handwashing and aseptic techniques. > Encourage Pt. to engage in early ambulation and have his SOs assist him in such activities.

and hinder tissue/skin healing, by inhibiting bacterial cell wall synthesis. > To allow continuous monitoring and assessment of Pt. condition.

> To prevent unnecessary exposure and contamination of the operative site which may delay healing. > For immediate replacement to prevent skin breakdown and contamination of operative site. > To promote healing and emphasize the importance of aseptic techniques in preventing infection/contamination of operative site. > To promote circulation at operative site for timely healing.

Name: Patient D Age: 32 Gender: Male Diagnosis: S/P Appendectomy Nursing Assessment O:> v/s taken as follows: T= 37.0 C PR= 81 bpm RR= 23 breaths/min BP= 110/70 mmHg > S/P appendectomy > with dry and intact dressing on RLQ of abdomen A:> Risk for infection r/t tissue trauma Explanation of the Problem Inflammation of the appendix Acute Appendicitis Appendectomy Tissue trauma on RLQ May provide portal of entry for pathogens through: > unnecessary exposure of surgical site > inadequate aseptic techniques especially in wound dressing > contact with Pt.’s, SOs’, and visitors’ hands or other body parts LTO:> Within 3 days of nursing intervention, the Pt. will maintain stable v/s and good skin integrity, characterized by absence of swelling, redness and pain on operative site. Objectives STO: >Within 8 hours of nursing intervention, the Pt. and SOs will verbalize ways in preventing infection/ contamination, specifically proper handwashing, and proper wound care. Nursing Interventions Dx:> Monitor v/s and record. > Assess operative site for signs of infection. Rationale

Date: June 28, 2008 Shift: 3-11 Ward: Private Room N3302 Evaluation > The Pt. and SOs verbalized ways in preventing infection/ contamination, specifically proper handwashing, and proper wound care.

> Elevation in rates may signal infection. > To provide baseline data for comparison. > To check for skin integrity and identify need for further management. > To prevent growth of MOs on dressings. > To prevent growth of MOs on linens and robes. > To prevent bacteria to harbor in the operative site and hinder tissue/skin healing, by inhibiting bacterial cell wall synthesis. > To allow continuous monitoring and assessment of Pt. for signs of infection.

Tx: > Provide regular wound dressing aseptically. > Change linens and Pt’s robes, as necessary. > Administer Zefocent (antibiotic), as ordered.

> Evaluation was not carried out due to time constraints. Pt. was endorsed to succeeding members of the health team for further management and evaluation.

Edx:> Encourage Pt. to verbalize any changes noted on operative site such as redness, swelling, and unusual/odorous

May result to infection

drainage on operative site. > Instruct Pt. and SOs to refrain from touching/scratching operative site. > Instruct Pt and SOs to immediately report when dressings are soaked. > Demonstrate to Pt. and SOs the proper way of giving wound care with emphasis on proper handwashing. > 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 contamination of operative site. > To prevent growth of MOs on dressings that may cause contamination of operative site. > To emphasize importance of aseptic techniques in preventing infection/contamination of operative site. > To prevent growth of MOs especially on operative site. > To promote circulation at operative site for timely healing.

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