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

 Instruct patient
and SO’s to
refrain from
touching/scratch  For immediate
ing operative replacement to
site. prevent skin
breakdown and
 instruct to contamination of
consume foods the operative
rich in protein site.
and Vitamin C.

Dependent:
 Administer  To promote
Ceftazidime 1gm circulation to the
q8H surgical site for
timely healing.

 Administer
Metronidazole
500 mg IVTT q8H  Protein helps the
body repair
damaged tissues
and Vitamin C
helps the body
form new
collagen.

 Binds to bacterial
cell membrane,
inhibit cell wall
synthesis.

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