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Cues

Nursing Diagnosis Impaired Skin Integrity related to skin/tissue trauma

Scientific Explanation Inflammation of the appendix Acute Appendicitis Appendectomy Dissection if right lower abdominal tissues Disruption of skin surface and destruction of skin layers Impaired skin/tissue integrity

Objectives/Plan of Care Within 8 hours of nursing intervention the pt will be ableto manifest the following: a.) intact sutures b.) dry and intact wound dressing c.) participation in passive ROM exercises

Nursing Interventions

Rationale

Evaluation

S> Hindi pa masyadomagalingangsugatko as verbalized by the patient O> S/P Appendectomy >with surgical incision at right lower abdominal area
>with dry intact dressing on the surgical site

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

>to check skin integrity, monitor progress of healing and identify need for further > Serve as baseline data >to promote circulation to the surgical site for timely healing

>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 > Support incision as in splinting when coughing and during movement >Encourage pt to verbalized his for any untoward feelings especially pain, discomfort as well as changes noted on operative site >Encourage pt to engage early ambulation and have SO s assist him in such activities

Within 8 hours of nursing intervention the pt be able manifest the following: a.) intact sutures b.) dry and intact wound dressing c.) participation in passive ROM exercises >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 allow continuous monitoring and assessment of pt. condition >to promote circulation to the

surgical site for timely healing >Instruct pt and SO s to immediately report when dressing are soaked

>Instruct pt and SO s to refrain from touching/scratching operative site

>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

>Provide regular dressing care

>Administer Chlorampenicol Sodium(antibiotic) as ordered

>to prevent bacteria harbor in operative site

Cues

Nursing Diagnosis

Scientific Explanation Inflammation of the appendix

Objectives/Plan of Care

Nursing Interventions >Monitor v/s and record

Rationale

Evaluation

S> Hindi namnakonilalagnat verbalized by the patient

Risk for infection related to tissue trauma

O> v/s taken as follow: BP:110/80 mmHg RR:22 cpm PR:68 bpm T: 37.0 C > S/P Appendectomy
>with dry intact dressing on the surgical site

Within 8 hours of nursing intervention the pt will be able verbalize Acute Appendicitis ways in preventing infection/contamination specifically proper hand Appendectomy washing, and proper Tissue trauma on wound care as evidenced by: RLQ abdomen May provide portal >maintain stable v/s >good skin integrity of entry for pathogens through: >absence of swelling redness and pain on >unnecessary operative site exposure of surgical site >inadequate aseptic techniques especially in wound dressing >contract with pt s, SO s and visitors hands or other parts

>Elevation in rates Within 8 hours of may signal infection nursing intervention the pt will be able verbalize >to provide ways in preventing >assess operative baseline data for infection/contamination site for signs of comparison and specifically proper hand infection identify need for washing, and proper further wound care as management evidenced by: >maintain stable v/s >change linens as >to prevent growth >good skin integrity necessary of microorganisms >absence of swelling on linens and beds redness and pain on operative site >Provide regular > to prevent >Evaluation was not dressing care unnecessary carried out due to time exposure and constraints. Pt was contamination of endorsed to succeeding operative site members of the health which may delay team for further wound healing management and evaluation >Instruct pt and SO s >for immediate

May result to infection

to refrain from touching/scratching operative site

replacement to prevent skin breakdown and contamination of operative site >to allow continuous monitoring and assessment of pt. condition

>Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage

>Encourage pt to engage early ambulation and have SO s assist him in such activities >Administer Penicillin G Sodium(antibiotic) as ordered

>to promote circulation to the surgical site for timely healing

>serve as prophylactic treatment and prevent bacteria to harbor on operative site

Kenneth Antonio B. Bacani, SN

Group 1

Nursing Care Plan

Callang General Hospital, Santiago City

Cues

Nursing Diagnosis

Scientific Explanation Inflammation of the appendix Acute Appendicitis Appendectomy Dissection if right lower abdominal tissues Disruption of skin surface and destruction of skin layers
Activation of nociceptors in dermis and tissues

Objectives/Plan of Care
Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced by a. ) verbalization of decrease pain form 5/10 to 2/10 b.) engagement in diversional activities such as socialization, watching TV, and listening mellow music

Nursing Interventions
>Monitor V/S and record

Rationale

Evaluation

S> Masakit ditto sa baba , while pointing at RLQ of abdomen. >rated pain as 5 on a scale of 10, where 1 as the lowest and 10 as the highest >characterized pain as pricking >reported that pain occurs everytime when pt moves or moved O> v/s taken as follows T: 37.0 C RR: 21 cpm PR: 64 bpm BP: 120/70 mmHg

Acute pain related to tissue damage 2nd to post appendectomy

>Elevation in rates suggest increased pain intensity and frequency


>Elevation in intensity and frequency may indicate worsening condition >Swelling, redness , and loose sutures may contribute to the pain felt by pt. and are indicative of further management >to lessen pain felt aggravated by movements

>Assess pain characteristics including location, intensity, and frequency >Assess surgical site for swelling, redness or loose sutures

> S/P Appendectomy


>with dry intact dressing on the surgical site >with guarding

>Promote adequate rest periods by temporarily limiting activity >Encourage pt to verbalize pain perception

Receptors send impulses to CNS for interpretation

>to allow further assessment of pain characteristics and

Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced by a. ) verbalization of decrease pain form 5/10 to 0/10 b.) engagement in diversional activities such as socialization, watching TV, and listening mellow music >verbal report that pain is completely releived >absence of facial grimacing upon performance of activities such as changing position, sitting ,standing and walking

behavior over the site >facial grimacing

Pain Perception Acute Pain


>Provide pt with diversional activities such as socialization, watching TV, and listening mellow music

evaluation of treatment / intervention >to help pt divert his attention to other matters than pain felt

> absence of guarding behavior over surgical site

>Encourage SO s to continue provision of diversional activities and a quiet environment >Administer Toradol (analgesic)as ordered

>to allow pt continue divert his attention

>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 relieved or lessen pain by inhibiting prostaglandin synthesis