Assessment Nursing Diagnosis Planning Interventions

S: “Gumatgatel day sugat Impaired tissue integrity r/t STG: 1. Assess site of impaired
ko.” surgical procedure tissue integrity and its
condition.
After 8 hours of nursing
O: Surgical wound noted at intervention, patient will be
the hypogastric region of able to participate in prevention
the abdomen. measures and treatment being
provided as evidenced by:

Itchiness noted.
a. Patient’s willingness
and initiative to be
treated.
Redness noted due to
scratching. 2. Assess changes in body
temperature,
b. Verbalization of altered specifically increased
sensation at site of in body temperature.
Dry and intact dressing
surgical wound.

3. Monitor site of
LTG: impaired tissue
integrity at least once
daily for color changes,
redness, swelling,
After 3 days of nursing warmth, pain, or other
interventions, patient’s surgical signs of infection.
wound displays timely healing
with no complications as
evidence by:
4. Observe for signs of
itching and scratching.

a. No itchiness and
redness.

b. Wound will be
decrease in size and
increase granulation
tissue.
5. Assess patient’s
nutritional status.

6. Provide tissue care as

 needed.

7. Maintain sterelity in
wound dressing
technique.

8. Administer antibiotics
as ordered, or cream
such as topical cream.

9. Instruct patient to avoid

rubbing and scratching
wound area.

10. Educate patient about

proper nutrition,
hydration, and methods
to maintain tissue
integrity.

11. Encourage the use of

pillows, foam wedges,
and pressure-reducing
devices.

12. Educate the patient the

need to notify the
physician or nurse.
 Drug Name Indication Contraindication Side Effects Adverse Effect

AMINO ACID

- provides - not
- No side effects were seen after - No adverse effects were seen
nutritional support contraindicated to
Route: Oral administering medications. administering medications.
for patients the patient

- Drug rash
with eosinophilia and systemi
s

- Exacerbation of systemic lup
erythematosus

- Hemolytic anemia
- Diarrhea, Difficulty
swallowing, Drug rash, - Hepatotoxicity
DOXYCYCLIN
Esophageal ulcer, Esophagitis,
E
facial redness, Headache, Hives, - Low platelet count (thrombo
- Pelvic - not Inflammation of the small
inflammatory contraindicated to intestine and colon (enterocolitis - Low white blood cell
Drug disease, the patient ), Lesions on the genitals count (neutropenia)
Classification: or anus, Loss of appetite - intracranial hypertension
Antibiotic
- No side effects were seen after - Pericarditis
administering medications.
- Serum sickness

- Toxic epidermal necrolysis

- No adverse effects were seen

administering medications.

Ferrous sulfate The prevention or Patients receiving Adverse Reactions of Ferrous Adverse Reactions of Ferrous
treatment of iron repeated blood Sulfate* Large doses may Large doses may aggravate pe
Brand Name: deficiency anemia transfusions ; aggravate peptic ulcer, regional regional enteritis, and ulcerati
due to inadequate anemia not due to enteritis, and ulcerative colitis.*
Ferrous sulfate Severe Iron Poisoning
diet malabsorption iron deficiency
Classification: pregnancy, and Severe Iron Poisoning
o Vomiting
blood loss.
Enzymatic o Vomiting or Severe abdominal pain
O The medicine is
mineral and Iron
not
preparation. or Severe abdominal pain o Diarrhea
contraindicated to
the patient o Dehydration o Hyperventil
o Diarrhea
o Pallor or cyanosis o Cardio
o Dehydration o collapse
Hyperventilation

o Pallor or cyanosis o
Cardiovascular collapse o the patient did not manifest
effects or adverse effects.

o the patient did not manifest

and side effects or adverse
effects.