Assessment Subjective: “kumikirot-kirot yung bandang inoperahan” as verbalized by the patient.

Objective:  Observed evidence of pain; facial grimace  Verbalized pain at the abdomen with a pain scale of 5/10  Guarding behaviour in the incision site.  Positioning to avoid pain

Diagnosis Acute pain related to presence of surgical incision as manifested by facial grimace and report of pain.

Planning Intervention After 4 hours of Independent: nursing intervention,  Assess pain, the patient will be noting location, able to verbalize characteristics, relief of pain or at severity (0-10). least pain is reduced Investigate and from pain scale 5/10 report changes in to 3/10 and also the pain as patient will be able to appropriate. appear relaxed.

Rationale  Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristics of pain may indicate developing abscess/ peritonitis, requiring prompt medical evaluation and intervention  Gravity localizes inflammatory exudates into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.

Evaluation After 4 hours of nursing intervention, the patient was able to verbalize pain is reduced from pain scale 5/10 to 3/10 and also the patient was able to appear relaxed.

 Keep at rest in semi-Fowler’s position.

 Encourage early ambulation. .  Administer analgesics as indicated.  Refocuses attention. and may enhance coping abilities. Collaborative:  Keep NPO/ maintain NG suction initially.  Decreases discomfort of early intestinal peristalsis and gastric irritation/vomitin g.  Relief of pain facilitates cooperation with other therapeutic interventions.  Promotes normalization of organ function. promotes relaxation.  Provide diversional activities.

Note: do not use heat because it may cause tissue congestion/ increase edema formation.  Soothes and relieve pain through desensitization of nerve endings. during initial 2448 hours as appropriate. Place ice bag on the abdomen periodically. .

swelling. Pt was endorsed to succeeding members of the health team for further management and evaluation >Monitor Vital Signs > Support incision as in splinting when coughing and during movement >Encourage pt to verbalized her for any untoward feelings especially pain.) intact sutures b. condition >to promote circulation to the surgical site for timely healing . monitor progress of healing and identify need for further > Serve as baseline data Evaluation Within 8 hours of nursing intervention the pt be able manifest the following: a.) dry and intact wound dressing >Evaluation was not carried out due to time constraints. loose sutures. discomfort as well as changes noted on operative site >Encourage pt to engage early ambulation and have SO’s assist him in such activities >to reduce pressure on the operative site >to allow continuous monitoring and assessment of pt.) dry and intact wound dressing Intervention >Assess operative site for redness.) intact sutures b.Assessment Subjective: “ Hindi pa masyado magaling ang sugat ko” as verbalized by the patient Objective: S/P Appendectomy  with surgical incision at right lower abdominal area  with dry intact dressing on the surgical site Diagnosis Impaired Skin Integrity related to skin/tissue trauma Planning Within 8 hours of nursing intervention the pt will be able to manifest the following: a. or soaked dressing Rationale >to check skin integrity.

>Instruct pt and SO’s to >to promote immediately report when circulation to the dressing are soaked surgical site for timely healing >Instruct pt and SO’s to refrain from touching/scratching operative site >for immediate replacement to prevent skin breakdown and contamination of operative site >Provide regular dressing >to avoid care accumulation of moisture at the operative site which may lead to skin breakdown >Administer >to prevent bacteria Metronidazole(antibiotic) harbor in operative as ordered site .

1 C > S/P Appendectomy >with dry intact dressing on the surgical site >change linens as necessary >Provide regular dressing care >Instruct pt and SO’s to refrain from touching/scratching operative site >Elevation in rates Within 8 hours of may signal infection nursing intervention the pt will be able verbalize >to provide ways in preventing baseline data for infection/contamination comparison and specifically proper hand identify need for washing.Assessment Subjective: ”Hindi naman ako nilalagnat”. and proper wound care as evidenced by: >maintain stable v/s >good skin integrity >absence of swelling redness and pain on operative site Intervention >Monitor v/s and record Rationale Evaluation >assess operative site for signs of infection Objective: Vital Signs taken as follows: BP:140/80 mmHg RR:28 cpm PR:93 bpm T: 37. as verbalized by the patient Diagnosis Risk for infection related to skin trauma Planning Within 8 hours of nursing intervention the pt will be able verbalize ways in preventing infection/contamination specifically proper hand washing. Pt was contamination of endorsed to succeeding operative site members of the health which may delay team for further wound healing management and evaluation >for immediate replacement to prevent skin breakdown and . and proper further wound care as management evidenced by: >maintain stable v/s >to prevent growth >good skin integrity of microorganisms >absence of swelling on linens and beds redness and pain on operative site > to prevent >Evaluation was not unnecessary carried out due to time exposure and constraints.

condition >Encourage pt to engage early ambulation and have SO’s assist him in such activities >Administer Penicillin G Sodium(antibiotic) as ordered >to promote circulation to the surgical site for timely healing >serve as prophylactic treatment and prevent bacteria to harbor on operative site . swelling and unusual/odorous drainage >to allow continuous monitoring and assessment of pt.contamination of operative site >Encourage pt to verbalized any changes noted on operative site such as redness.

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