COLLEGE OF NURSING

Silliman University Dumaguete City KARDEX FOR IMMEDIATE POSTOPERATIVE PHASE

CUES/ EVIDENCES
Subjective: Client verbalized, y Sakit e lihok tungod sa tahi sa tiyan nako. y Basin unya ma tangtang ning tahi sa ako tiyan kung mag lihok lihok ko. Rated pain as 9 from the pain rating scale of 0 to 10, where 10 as the most painful and 0 as the minimal or no pain felt

NURSING DIAGNOSIS
Impaired skin/tissue integrity related to mechanical interruption of skin (presence of surgical wound) secondary to appendectomy

OBJECTIVES
Within our 2 to 4 hours immediate postoperative nursing care, the client will manifest intact skin integrity as evidenced by: a. Absence of inflammation, redness, purulent discharges on skin or operative site Independent:

INTERVENTIONS

EVALUATION
After our 2 to 4 hours immediate postoperative nursing care, the goals were: a. Fully met There was no presence of inflammation, redness or purulent discharges noted on the surgical site.

1. Assess vital signs frequently. 2. Inspect surrounding skin for erythema, maceration, edema or bleeding and note odors emmited from the surgical incision. 3. Do proper aseptic wound care using appropriate barrier dressings, wound coverings or skin protective agents as needed

b. Vital signs will remain in normal range: T = 36.5 - 37.5C; afebrile P = 60 100 bpm; regular and strong R = 12 20 cpm; regular, silent, effortless, without use of accessory muscles

4. Cleanse skin surface with diluted hydrogen peroxide or running water and mild soap after incision is sealed. 5. Check tension of dressings. Apply tape at center of incision to outer margin of dressing. 6. Give health teaching on proper wound care or dressing and

b. Partially met T = 35.8 C PR = 80 bpm, strong, regular RR = 24 cpm shallow, regular, regular with slight use of accessory muscles

Objective: y Vital signs T = 35.8 C PR = 80 bpm, strong,

regular RR = 22 cpm shallow, regular, with slight use of accessory muscles BP = 120/70 mmHg y Surgical operation done: Appendectomy Presence of surgical wound on right lower quadrant of abdomen Spinal anesthesia with Bupivacaine HCl 0.5% SAB 20 mg General anesthesia with succinylcholine GETA 300 mg; 100 mg

BP = 110 140/60 90 mmHg c. Demonstration of behaviours to promote timely wound healing or prevent skin breakdown such as not touching the wound or asking the nurse to change the dressing often and splinted decision correctly

importance of not touching the wound. 7. Give health teaching on importance of eating nutritious food such as green leafy vegetables and fresh fruits. 8. Give health teaching on the importance of early ambulation. Dependent: 1. Administer prescribed medications: - metronidazole 500 mg IVTT q 8H - ampicillin sulbactam 750 mg IVTT q 8H - nalbuphine HCl 10 mg IVTT 2. Refer to physician regarding the change of dressing.

BP = 130/80 mmHg c. Fully met Demonstrated behaviors to promote timely wound healing or preventing skin breakdown by refraining in touching the wound.

d. Report any altered sensation or pain at site of skin impairment

d. Fully met No altered sensation reported. Verbalized, Mu sakit nalang siya if kanang mangusog ko pag ayo.

Presence of redness on the skin around the surgical wound Minimal red discharges on wound dressing

e. Absence of discomforts such as itching or pain on the surgical site

e. Partially met No itching on the surgical site noted. Rated pain as 4 from the pain rating scale of 0 to 10.

f.

Display timely healing of surgical wound without

f.

Fully met

Presence of minimal

complications

red discharge on wound dressing. g. Fully met Verbalized, Pag sugtan nako mu kaon, mga gulay ako dapat kaunon para dali ma ayo ako samad.

g. Verbalized understanding of eating nutritious foods to have good skin integrity as an aid to hasten wound healing