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CUES

NURSING DIAGNOSIS

ANALYSIS

GOAL

NURSING INTERVENTION

RATIONALE

EVALUATION

S: Nsakit pay lang toy sugat ko. O: >with pain scale of 7/10 >with facial grimaces >weak appearance >guarding behavior V/S: T: 36.6 C P: 67 bpm R: 16 cpm BP: 100/80 mmHg

P: Pain, Acute E: t/t disruption of skin, tissue and muscle integrity secondary to Surgical incision (Appendectomy) S: AEB: patients verbalization of pain with a pain scale of 7/10, facial grimace, guarding behavior and weak appearance

Appendectomy Surgical Incision Disruption of skin, tissue and muscle integrity Stimulation of sensory nerve endings Pain

Date: Jan 2013 Shift: 7-3 Time: 8:00 am After 6 hrs of nursing intervention the patient will report that her pain is lessen from a pain scale of 7/10 to 1/10.

Independent >Assess location, characteristic, onset, duration, frequency , quality and severity of pain >Note location of surgical incision >Perform assessment each time pain occurs, note and investigate changes from previous reports >Monitor V/S >Provide quiet environment and encourage adequate rest period >Encourage use of relaxation technique and diversional activities >Provide additional comfort measures such as back rub, changing patients position, change linen as necessary Dependent >Administer analgesic as ordered Collaborative >Instruct patients significant others to help patient divert pain into other things

>To assess the etiology or precipitating factors

Date: Jan 2013 Time:2:00 pm

Medical Nursing Incredibly Easy,

Goal met AEB: Patient reported that her pain was >As this can lessened from a influence the amount pain scale of 7/10 of post-op to 1/10 after 6 experience hours of nursing >To rule out intervention. worsening of underlying condition or development of complication >V/S are usually altered in acute pain >To prevent fatigue >To encourage sense of control and improve coping activities/helps control or alleviate pain >To relieve general discomfort >To maintain acceptable level of pain >To help control or alleviate pain

S:Medyo agsakit-sakit gamin Toy sugat ko lalo no aggunaygunay nak adding. O: >Facial grimace upon moving >patient puts her hand above surgical incision when moving >Slowed movement >weak appearance >Inability to ambulate or walk without assistance from others V/S: T: 36.6 C P: 67 bpm R: 16 cpm BP: 100/80 mmHg

P: Activity Intolerance E: r/t limited mobility secondary to pain S: AEB: patients verbalization of pain upon moving, facial grimace, patient puts her hand above surgical incision when moving, slowed movement and weak appearance

Appendectomy Surgical Incision Disruption of skin, tissue and muscle integrity Stimulation of sensory nerve endings Pain Increase of pain upon moving Limited mobility Activity intolerance Medical Nursing Incredibly Easy, Pellico, L.H.,

Date: June 23, 2009 Shift: 7-3 Time: 8:00 am After 6 hours of nursing intervention the patient will be able to move or ambulate without assistance from others.

Independent >Assess patients ability to ambulate or move independently and safely >when standing allow legs to dangle first; support him from the side > Increase the clients time out of bed by 15 minutes each time. Allow him to set a comfortable rate of ambulation, and agree on a distance goal for each shift >Encourage the client to increase activity when pain is at a minimum or after pain relief measures take effect. > Plan regular rest periods according to the clients daily schedule >Assist client in learning or trying to walk on her own >Teach the patient the importance of ambulating after surgery Collaborative >Instruct significant others to assist patient to promote comfort measures to provide

>To assist in correcting/dealing with the situation >to prevent hypostatic hypertension >Gradual increases toward mutually established, realistic goals can promote compliance and prevent overexertion >Lesser pain will allow the patient to concentrate to walk or ambulate on her own > Regular rest periods allow the body to conserve and restore energy >Demonstrating appropriate safety measures to prevent injury >Motivate or encourage patient to move or ambulate on her own

Date: June 23, 09 Time:2:00 pm Goal Met AEB: Patient was able to ambulate without assistance from others after 6 hours of nursing intervention.

relief of pain S:Medyo nagatel ading, nagmayat nga kudkuden. O: >disrupted skin layers >wound area is warm to touch >(+)slight swelling at the incision site V/S: T: 36.6 C P: 67 bpm R: 16 cpm BP: 100/80 mmHg P: Impaired Skin Integrity E: r/t disrupted skin layers secondary to surgical incision S: AEB verbalization of itchiness on the incision site, disrupted skin layers, wound area is warm to touch, (+) swelling at the incision site Surgical Incision Destruction of skin layers Broken skin and traumatized tissue Impaired Skin integrity Date: June 23, 2009 Shift: 7-3 Time: 8:00 am >To enhance patients ability or participate in activities Date: June 23, 09 Time:2:00 pm Goal Met AEB: (-) Scratching on the incision site after 6 hours of nursing intervention.

Independent >Inspect/assess incision site for redness, swelling or After 6 hrs signs of evisceration of nursing >Keep the incision site intervention clean and dry, carefully the patient change the dressing will avoid >Regularly clean the wound scratching at aseptically Medical Nursing the incision > Minimize skin irritation Incredibly Easy, site Pellico, L.H., >Instruct patient to increase intake of foods rich in protein, minerals and vitamins >Assess for presence or absence of local wound infection >Instruct patient to have adequate rest and sleep

>Redness or swelling indicates wound infection >To assist bodys natural process of infection >To promote healing and prevent infection > Preventing skin irritation eliminates a potential source of microorganism entry >They aid in skin healing

>Teach and assist the client in the following: a.supporting the surgical site when moving b.Splinting the area when

>Provides for early detection of developing infectious process > Adequate rest and sleep helps in faster healing and recovery

O: >presence of wound (surgical incision) at the right iliac region >disruption of skin layers >(+) slight swelling at the incision site > wound area is warm to touch

P: Risk for Infection E: r/t surgical procedure (Appendectomy)

S: AEB: presence of surgical wound, disruption of skin layers, (+) Lab slight swelling, >WBC is slightly wound area is elevated,12.0 warm to touch x10^9/L V/S: T: 36.6 C P: 67 bpm R: 16 cpm BP: 100/80 mmHg

Surgical Procedure (Appendectomy) Surgical Incision Destruction of Skin Layers Broken Skin and traumatized tissue Increased risk for environmental exposure to pathogens Risk for Infection

Date: June 23, 2009 Shift: 7-3 Time: 8:00 am

coughing, sneezing, or vomiting Dependent >Administer antibiotic as ordered Collaborative >Instruct patients significant others the proper way of caring wound Independent >Emphasize good hand washing technique for all individuals coming in contact with the patient >Inspect incision and dressing

After 6 hours of nursing intervention the occurrence of infection will be prevented as evidenced by no s/sx of infection will appear like diaphoresis, Medical Nursing chills, Incredibly Easy, abdominal Pellico, L.H., pain and fever.

> A wound typically requires 3 weeks for strong scar formation. Stress on the suture line before this occurs can cause disruption

Date: June 23, 09 Time:2:00 pm Goal Met AEB:

>(-) chills, >(-) diaphoresis >(-) report of >To prevent increasing infection and abdominal pain promote healing >afebrile with a body temp of 36.9C >To promote healing after 6 hours of and prevent nursing infection intervention

>Monitor V/S . Note onset of fever, chills, diaphoresis, reports of increasing abdominal pain >Regularly clean the wound aseptically >Change wound dressings as indicated, using aseptic technique >Examine wound in terms of appearance, odor and quantity of drainage

>To prevent crosscontamination and to reduce risk for acquired infection >Provides for early detection of developing infectious process >Suggestive of presence of infection/developing sepsis

>Observe for localized sign of infection

>To promote healing and prevent infection >To prevent infection

Dependent >Administer antibiotics as ordered

>Monitor WBC

Collaborative > Instruct patients significant others the proper way of caring wound

>Identify presence of healing and provides for early detection of wound infection >Provides for early detection of developing infectious process

>Antibiotics inhibits DNA synthesis in specific anaerobes causing cell death >elevated WBC indicates infection

>To promote healing and prevent infection