Assessment Diagnosis Scientific Rationale Goal Interventions Rationale Evaluation

Subjective: Impaired skin integrity Impaired skin integrity is After 1 hour of nursing Independent: . After 1 hour of nursing
related to skin/tissue a damage to intervention the patient intervention the patient
“Inoperahan ako, trauma as evidenced by integumentary or  Assess operative  To check skin
will be able to: was able to:
tinanggal Gallbadder ko subcutaneous tissues. sites for redness, integrity,
the surgical incision in
.” as verbalized by the The integumentary act as  Describe measures swelling, loose monitor progress  Described measures
the abdomen. a physical barrier of healing and
patient to protect and heal sutures, or to protect and heal
preventing penetration identity need for
the tissue, including soaked dressing. the tissue, including
“Mahaba yong sugat na against threats from the further.
external environment. wound care. wound care such as
tinahi noong inoperahan
However, these tissues  Verbalize intake of vitamin C
ako saking tiyan”. As  Monitor V/S
can be damaged by understanding of  Serve as baseline rich foods and using
verbalized by the patient. several circumstances. q4H. data.
plan to heal tissue aseptic techniques in
Factors that can cause and prevent injury. changing dressing.
injury or tissue damage
include physical trauma,  Can impair or
Objective:  Check tension of  Verbalized
chemical injury, radiation occlude
and surgical incision ( dressing. understanding of
- S/P Emergenncy circulation to
Emergenncy Open wound. plan to heal tissue
Open
Cholecystectomy Cholecystectomy). and prevent injury.
- Dry intact  Reinforce initial  Protects wound  “Naintindihan ko
dressing noted Reference:
dressing and from mechanical nurse, napaka-
on the surgical Nurse’s Pocket Guide
change as injury and importante talaga na
site. Diagnoses, Prioritized
contamination. linisin at alagaan ko
Interventions, and indicated use
- 11 cm surgical
Rationales p. 757 strict aseptic itong tinahian ko”
incision at right
lumbar area of techniques.
the abdomen
- Surgical wound  Assist in active  To promote
free from exercise circulation to the
redness, swelling surgical site for
movement such
and discharges. timely healing.
as bed
positioning,
sitting, standing,
 walking.

 Health teaching
 To reduce
imparted with
pressure on the
emphasis in operative site.
supporting
incision as in
splinting when
coughing and
during
movement.

 Encourage  To allow
patient to continuous
verbalize for any monitoring and
untoward assessment of
feelings patient
condition.
especially pain,
discomfort as
well as changes
noted on the
operative site.

 Instruct patient
 For immediate
or SO’s to report replacement to
when dressings prevent skin
are soaked. breakdown and
contamination of
the operative
site.

 Instruct patient  To promote

and SO’s to circulation to the
surgical site for
 refrain from timely healing.
touching/scratchi
ng operative site.

 instruct to  Protein helps the

consume foods body repair
rich in protein damaged tissues
and Vitamin C. and Vitamin C
helps the body
form new
collagen.
Dependent:

 Administer  Binds to bacterial

Ceftazidime 1gm cell membrane,
q8H inhibit cell wall
synthesis.

 Inhibits nucleic
 Administer acid synthesis by
Metronidazole disrupting DNA
500 mg IVTT q8H and causing
strand breakage.
Hinders growth
of selected
organisms,
including most
anaerobic
bacteria and
protozoa.