Cues Nursing Objectives/Plan of Nursing Interventions Rationale Evaluation

Diagnosis Care

S> “ Hindi pa Impaired Skin Within 8 hours of >Assess operative site for redness, >to check skin integrity, Within 8 hours of
masyado Integrity related nursing swelling, loose sutures, or soaked monitor progress of nursing
magaling ang to skin/tissue intervention the pt dressing healing and identify intervention the pt
sugat ko” as trauma will be able to need for further be able manifest
verbalized by manifest the the following:
the patient following: >Monitor Vital Signs > Serve as baseline data a.) intact sutures
a.) intact sutures b.) dry and intact
O> S/P b.) dry and intact >Assist in passive movements(while >to promote circulation wound dressing
Appendectomy wound dressing 8hrs. flat on bed) such as bed turning to the surgical site for c.) participation in
>with surgical c.) participation in and passive ROM exercise and active timely healing passive ROM
incision at right passive ROM exercise thereafter movements such exercises
lower abdominal exercises as bed position, sitting, standing,
area walking >Evaluation was
>with dry intact not carried out due
dressing on the > Support incision as in splinting >to reduce pressure on to time constraints.
surgical site when coughing and during the operative site Pt was endorsed to
movement succeeding
members of the
>Encourage pt to verbalized his for >to allow continuous health team for
any untoward feelings especially monitoring and further
pain, discomfort as well as changes assessment of pt. management and
noted on operative site condition evaluation

>Encourage pt to engage early >to promote circulation

ambulation and have SO’s assist him to the surgical site for
in such activities timely healing
>Instruct pt and SO’s to immediately >to promote circulation
report when dressing are soaked to the surgical site for
timely healing

>Instruct pt and SO’s to refrain from >for immediate

touching/scratching operative site replacement to prevent
skin breakdown and
contamination of
operative site

>Provide regular dressing care >to avoid accumulation

of moisture at the
operative site
which may lead to skin
breakdown

>Administer Chlorampenicol >to prevent bacteria

Sodium(antibiotic) as ordered harbor in operative site
Cues Nursing Objectives/Plan of Care Nursing Interventions Rationale Evaluation
Diagnosis

S>”Hindi namn ako Risk for infection Within 8 hours of nursing >Monitor v/s and >Elevation in rates Within 8 hours of nursing
nilalagnat” related to tissue intervention the pt will record may signal intervention the pt will
verbalized by the trauma be able verbalize ways in infection be able verbalize ways in
patient preventing preventing
infection/contamination >assess operative site >to provide infection/contamination
specifically proper hand for signs of infection baseline data for specifically proper hand
O> v/s taken as washing, and proper comparison and washing, and proper
follow: wound care as evidenced identify need for wound care as evidenced
by: further by:
(PALAGAY PO V/S) >maintain stable v/s >change linens as management >maintain stable v/s
>good skin integrity necessary >good skin integrity
> S/P >absence of swelling >to prevent growth >absence of swelling
Appendectomy redness and pain on of microorganisms redness and pain on
>with dry intact operative site >Provide regular on linens and beds operative site
dressing on the dressing care >Evaluation was not
surgical site > to prevent carried out due to time
unnecessary constraints. Pt was
exposure and endorsed to succeeding
contamination of members of the health
operative site team for further
which may delay management and
>Instruct pt and SO’s wound healing evaluation
to refrain from
touching/scratching >for immediate
operative site replacement to
prevent skin
breakdown and
contamination of
 >Encourage pt to operative site
verbalized any
changes noted on >to allow
operative site such as continuous
redness, swelling and monitoring and
unusual/odorous assessment of pt.
drainage condition

>Encourage pt to
engage early
ambulation and have
SO’s assist him in >to promote
such activities circulation to the
surgical site for
>Administer Penicillin timely healing
G Sodium(antibiotic)
as ordered
>serve as
prophylactic
treatment and
prevent bacteria to
harbor on
operative site

Cues Nursing Diagnosis Objectives/Plan of Nursing Rationale Evaluation

Care Interventions
S> “Masakit ditto sa Acute pain related to Within 6-8 hours of >Monitor V/S and >Elevation in rates Within 6-8 hours of
baba”, while pointing tissue damage 2nd to nursing intervention, record suggest increased nursing intervention,
at RLQ of abdomen. post appendectomy the pt will be able to pain intensity and the pt will be able to
>rated pain as 5 on a manifest ability to frequency manifest ability to
scale of 10, where 1 as cope with cope with
the lowest and 10 as incompletely relieved >Assess pain incompletely relieved
>Elevation in intensity
the highest pain as evidenced by characteristics pain as evidenced by
and frequency may
>characterized pain as a. ) verbalization of including location, a. ) verbalization of
indicate worsening
pricking decrease pain form intensity, and decrease pain form
condition
>reported that pain 5/10 to 2/10 frequency 5/10 to 0/10
occurs everytime b.) engagement in b.) engagement in
>Swelling, redness ,
when pt moves or diversional activities >Assess surgical site diversional activities
and loose sutures may
moved such as socialization, for swelling, redness such as socialization,
contribute to the pain
watching TV, and or loose sutures watching TV, and
felt by pt. and are
O> v/s taken as follows listening mellow music listening mellow music
indicative of further
>verbal report that
management
(PALAGAY V/S DITO) pain is completely
>Promote adequate releived
>to lessen pain felt
> S/P Appendectomy rest periods by
aggravated by
>absence of facial
>with dry intact temporarily limiting grimacing upon
movements
dressing on the activity performance of
surgical site activities such as
>with guarding >Encourage pt to changing position,
>to allow further
behavior over the site verbalize pain sitting ,standing and
assessment of pain
>facial grimacing perception walking
characteristics and
> absence of guarding
evaluation of
behavior over surgical
treatment /
site
intervention
>Provide pt with >Evaluation was not
>to help pt divert his
diversional activities carried out due to
attention to other
such as socialization, time constraints. Pt
matters than pain felt
watching TV, and was endorsed to
listening mellow music succeeding members
of the health team
for further
>Encourage SO’s to >to allow pt continue management and
continue provision of divert his attention
evaluation
diversional activities
and a quiet
environment

>Administer Toradol >to relieved or lessen

(analgesic)as ordered pain by inhibiting
prostaglandin
synthesis