ASSESSM

ENT

ANALYSIS

RATIONALE

PLANNIN
G

INTERVENTION

RATIONALE

EVALUATI
ON

S> Hindi
pa
masyado
magaling
ang
sugat ko
as
verbalized
by
the patient

Impaired
Skin
Integrity
related to
skin/tissue
trauma as
evidenced
by the
surgical
incision at
right lower
abdominal
area due to
appendecto
my

Due to the
surgical
procedure
(appendecto
my) as
management
to acute
appendicitis,
an incision at
right lower
abdominal
area is made
causing the
disruption of
skin surface
and its
integrity.

After the 8
hours
of nursing
interventio
n the
client will
be able
to
manifest
the
following:
a.) intact
sutures
b.) dry and
intact
wound
dressing
c.)
participati
on
in passive
ROM
exercises

>Assess operative
site for
redness, swelling,
loose
sutures, or soaked
dressing

>to check skin

integrity, monitor
progress of healing
and identify need
for further

After the
series
of nursing
interventio
n the goal
has been
met as
manifested
by the
following:
a.) intact
sutures
b.) dry and
intact
wound
dressing
c.)
participatio
n
in passive
ROM
exercises

O> S/P
Appendect
o
my
>with
surgical
incision at
right lower
abdominal
area

> Serve as baseline

data
>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
>Encourage pt to
verbalized
his for any untoward
feelings
especially pain,
discomfort as

>to promote
circulation to the
surgical site for
timely healing

>to allow
continuous
monitoring and
assessment of pt.
condition

>to promote
circulation to the
surgical site for

well as changes
noted on
operative site
>Encourage pt to
engage
early ambulation and
have
SOs assist him in
such
activities
>Instruct pt and SOs
to
immediately report
when
dressing are soaked
>Instruct pt and SOs
to
refrain from
touching/scratching
operative
site
>Provide regular
dressing
care

>Administer
antibiotic therapy as

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 site
which may lead to
skin breakdown
>to prevent
bacteria harbor in
operative site

ordered

ASSESSM
ENT

ANALYS
IS

RATIONALE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

S>Hindi
namn
ako
nilalagnat
verbalized
by
the patient

Risk for
infection
related
to
tissue
trauma

Due to the
surgical
procedure
(appendectom
y) as
management
to acute
appendicitis,
an incision at
right lower
abdominal
area is made
causing the
disruption of
skin surface
making it at
risk for being
invaded by
pathologic
organism

After the 8
hours of
nursing
intervention
the client
will be able
verbalize
ways in
preventing
infection/
contaminatio
n 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

>Elevation in rates
may
signal infection

After the series

of
nursing
intervention the
goal has been
met
as evidenced by:
>maintain stable
v/s
>good skin
integrity
>absence of
swelling redness
and pain on
operative site

O> v/s
taken as
follow:

>assess operative
site for signs of
infection

>change linens as
necessary
>Provide regular
dressing care

>Instruct pt and
SOs to refrain
from touching/
scratching
operative
site
>Encourage pt to
verbalized any
changes

>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 site which
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