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Subjective: “Naoperahanakosatagiliranbandangkanan ”, as verbalized by the client.
Objectives: -disruption of skin surface(Epidermis) -disruption of skin layer (Dermis) -Appearance -kind of suture -Inflammation -types of drain -amount of secretions, color, consistency and odor.
Impaired skin integrity related to surgical incision secondar y to
Long term: After 3-4 days of nursing interventions, the client will be able to achieve progressive healing of surgical wounds without complications. - Discuss importance of early detection of skin damages or complication.
Short term: After 1 hr. of nursing interventions, the client will be able to:
- Instruct proper hygiene and selfcare as well in her surroundings.
- Express willingness to participate in the prevention of further complication.
-Instruct to use appropriate barrier/ dressing.
-Proper hygiene will prevent infection, complication and occurrence of any disease. -to protect the wound and/ or surrounding tissue
After 3-4 days of nursing interventions, the client achieved progressive healing of surgical wounds without complications .
-Change surgical or other wound dressing as indicated.
Short term: After 30 mins. of nursing
-Provide optimum nutrition by increasing amounts of calories.Demonstrate proper hygiene and maintenance of the skin.Verbalized understanding about methods that promotes healing. -Promote healing and general good health . . -to promote circulation improve strength and reduce risks associated with immobility . -Support surgical Demonstrated proper hygiene and maintenance of the skin. Vitamin A and C. proteins. regular exercise. interventions.Verbalizeunderstandin g about methods that promotes healing.Expressed willingness to participate in the prevention of further complication. the client was able to: -Encourage early ambulation. -Periodically measure wound and observe for complications such as infection or dehiscence. -moistened dressings are favourable site for microorganis m to culture. .
incision (E. -to prevent the occurrence of dehiscence and evisceration Dependent: -Administer prescribed medication such as_____________ _ -to monitor healing process and provide for timely intervention as needed . Splinting when coughing) -to monitor progress wound healing -Encourage client to adhere to medical regimen and follow-up care.g.
-Vitamin C promotes wound healing and diuretics decreases renal vascular resistance and may increase renal blood flow Assessment Diagnosi s Planning Intervention s Independent: Rationales Evaluation Subjective: “Nahihirapanakonggawinangmgabagaykagayangpagpapalitng Self-care Long term: deficit After 2-4 due to Long term: -Encourage -Enhances .
the client will be able to increase strength and perform self-care activity within level of own ability. Objectives: -weakness -need assistance of significant others -Guarding behaviour presence of surgical incision days of nursing interventions . within level maximizes of own participation ability Short term: -Assist client in leaving After 30 and mins. of demonstratio nursing interventions n appropriate . occupational / diversion/ recreational activities. pain or discomfort Short term: After 30 mins.damit at pagpuntasabanyo”. the client’s strength increased and performed self-care -limits activities fatigue. participation in self-care. the client was able to: --verbalized willingness and . the client will be able safety measures to: such as ideal toilet practice for -verbalize postwillingness operative and -to prevent injuries. of nursing interventions . self-concept and selfindependenc e -Identify energy conserving technique for ADLs After 2-4 days of nursing interventions . as verbalized by the client.
demonstrate participation in activities patient. -Discuss -to sustain client motivation -verbalize information understandin that provides g of evidence of situations daily/ and weekly individual progress treatment regimen and safety -Encourage -promotes measures adequate wellbeing intake of and fluid/ maximizes nutritious energy foods production demonstrate d participation in activities -verbalized understandin g of situations and individual treatment regimen and safety measures Dependent: -administer .
-to permit maximal effort/ involvement in activity .to alleviate if pain is present.
of nursing interventions. 10 as the highest) -Discomfort -Guarding behaviour -weakness Short term: After 30 mins. as verbalized by the client. calm activities. After 2-4 days of nursing interventions. -alterations from normal may be signs of infection. the client was able to: -verbalize understanding about the methods that provide relief. Short term: -to provide comfort After 30 mins. -Instruct in/ encourage use of relaxation exercise . the client’s strength increased and performed selfcare activities within level of own ability -provide quiet environment.Assessment Diagnosis Planning Interventions Independent: Rationales Evaluation Subjective: “Medyomasakit pa angtahikokapagnagsasalit a at gumagalawako.”. the client will be able to: -Vital signs were monitored every 1 hour until stable. the client will be able to state that degree of pain is tolerable -Discuss impact of -to maximize pain on level of lifestyle/independence functioning and ways. Long term: Objectives: -Degree of pain: 3(3 out of 10. Acute pain related to postoperative abdominal incision Long term: After 3-4 days of nursing interventions. of nursing interventions.
healing and regeneration.-Demonstrate use of relaxation skills and divisional activities as indicated for individual situations. tissue growth. -to assist in muscle and generalized relaxation. such as focused breathing and diaphragmatic breathing. --verbalized willingness and demonstrated participation in activities -Encourage adequate rest periods to prevent fatigue and this promotes healing by reducing basal metabolic rate and allowing oxygen and -to be utilized for nutrients. -verbalized understanding of situations and individual treatment regimen and safety measures Dependent: -administer analgesic/pain reliever and antibiotics as indicated to maximal dosage as needed to .
maintain acceptable level of pain. -antibiotics are used to treat and infections caused by susceptible pathogens in skin structure infections. PROBLEM PRIORITIZATION DATE IDENTIFIED CUES NURSING DIAGNOSIS JUSTIFICATION This diagnosis has to be .
as verbalized by the client. Acute pain related to post-operative abdominal incision Objectives: -Degree of pain: 3(3 out of 10.”. Pain can affect the treatment and cooperation of the patient. physiological needs must be prioritized first. Subjective: “Naoperahanakosatagiliransakanan”. Impaired skin integrity related to surgical incision. as verbalized by the client. This is also an actual problem. 10 as the highest) -Discomfort -Guarding behaviour -weakness the first prioritized problem because this is an actual problem and based on Maslow’s Hierarchy of Needs. Acute pain is a physiological dimension and pain causes changes to the client’s homeostasis.Subjective: “Medyomasakit pa angtahikokapagnagsasalita at gumagalawako. Interventions needed to address this . thus slowing down his recovery. it is the 5th vital sign. It also limits his movements as stated by the client. The client has impairment in the integrity of her skin due to surgical procedure done.
Objectives: -disruption of skin surface (Epidermis) -disruption of skin layer (Dermis) -Appearance -kind of suture -Inflammation -types of drain -amount of secretions. Objectives: -weakness -need assistance of significant others -Guarding behaviour Based on Maslow’s hierarchy of needs. Subjective: Self-care deficit due to presence of “Nahihirapanakonggawinangmgabagaykagayangpagpapalitngdamit surgical incision. proper dressing. Hygiene including bathing. consistency and odor. as verbalized by the client. grooming. oral care and other ADLs is in the physiological needs. this diagnosis is the third to be prioritized and give appropriate interventions in order to reduce discomfort of the skin due to . problem to prevent further impairment to the client’s current condition. color. at pagpuntasabanyo”. Thus.
presence of pain. This also could contribute to the disease process if not resolve. Subjective: “Nagpapacheck-up lngakosa doctor kapag may masakitnataglaga at kapagpansinkongnababagonapagtatrabahoko”. . This is the 4thprioritized nursing diagnoses because this could hinder the process of recovery and healing of the wounds. impairment and prevent the occurrence of any infection. Subjective: Risk for infection related to: -surgical incision -presence of Objectives: Infection is invasion and multiplication of pathogenic microorganisms in a bodily part or tissue. as verbalized by the client. Knowledge Deficit Objectives: -asking questions related to the disease -inaccurate follow of instructions -inappropriate or exaggerated behaviours.
. because actual problem should be solve first. This is the 5thprioritized nursing diagnosis because according to the rule risk problem should prioritized least. The fact that the patient has incision site would make him more vulnerable in developing infection.-presence of surgical incision drains -poor hygiene which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms.
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