Nursing care plan

ASSESSMENT SUBJECTIVE: Hindi pa masyado magaling ang sugat ko as verbalized by the patient OBJECTIVE: >S/P Appendectomy > with surgical incision at the right lower abdominal area >with dry intact dressing at the surgical site VS of: BP-110/70mmHg PR-65 bpm RR-17 bpm T-37.2 C

DIAGNOSIS Impaired skin integrity related to skin/tissue trauma

PLANNING Within 8 hours of nursing intervention the patient will be able to manifest the following: a) Intact sutures b) Dry and intact wound dressing c) Participation in passive ROM exercise

INTERVENTION INDEPENDENT: Assess operative site for redness, swelling, loose sutures, or soaked dressing. Monitor vital signs. Assist in passive movements (while 8 hrs. flat on bed) such as bed turning and passive ROM exercise and active exercise thereafter movements such as bed position, sitting, standing and walking. Encourage pt to verbalize his for any untoward feelings especially pain, discomfort as well as changes noted on operative site.

RATIONALE

EVALUATION Goal met. Within 8 hours of nursing intervention the pt. was able manifest the following: a.) intact sutures b.) dry and intact wound dressing c.) participation in passive ROM exercises

To check integrity monitor progress of healing.

Serve as baseline data. To promote circulation to the surgical site for timely healing.

To allow continuous monitoring and assessment of patient condition.

To promote circulation to Encourage pt to engage the surgical site for timely early ambulation and healing. have watcher assist him in

such activities. Instruct pt and watcher For immediate to immediately report replacement to prevent when dressing are soaked. skin breakdown and contamination of operative site. Instruct pt and watcher to refrain from touching/scratching operative site. Provide regular dressing care. COLLABORATIVE: Administer Ampicillin+Sulbactam (antibiotic) as ordered. Simultaneously builds and breaks down portions of the cell wall of as they grow and divide. To avoid accumulation of moisture at the operative site this may lead to skin breakdown. To prevent bacteria harbour in operative site.