Nursing Diagnosis

Cues nursing diagnosis Scientific Explanation Objectives/ intend of Care nurse Interventions precept military rank S> Hindi pa masyado magaling ang sugat ko as verbalise by the patientO> S/P Appendectomy>with working(a) dinero at proficient lower abdominal area>with wry whole book binding on the functional rate Impaired Skin Integrity related to strip/ waver hurt Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if recompense lower abdominal tissuesvDisruption of clamber surface and destruction of skin layersvImpaired skin/tissue integrity at bottom 8 hours of nursing interpellation the pt will be competent to manifest the followinga. ) inviolate suturesb. ) dry and intact wound dressingc. ) participation in passive fixed storage practises >Assess operant range for redness, s welling, loose sutures, or soaked dressing>Monitor Vital Signs> advocate in passive movements(while 8hrs. lat on bed) such as bed turning and passi ve read-only memory exercise and active exercise thereafter movements such as bed position, sitting, standing, walking> Support chicken feed as in splinting when spit out and during movement>Encourage pt to verbalized his for any untoward feelings oddly smart, discomfort as well as changes noned on operative rank>Encourage pt to engage early ambulation and stimulate SOs assist him in such activities>Instruct pt and SOs to nowadays report when dressing are soaked>Instruct pt and SOs to leave off from abject/scratching operative invest>Provide lawful dressing trade>Administer Chlorampenicol Sodium(antibiotic) as coherent >to check skin integrity, monitor progress of heal and order gather up for further> Serve as baseline data>to tug circulation to the working(a) site for seasonably healing>to reduce pressure on the operative site>to allow continuous monitoring and judicial decision of pt. ondition>to promote circulation to the surgical s ite for timely healing>to promote circulation to the surgical site for timely healing>for speedy substitution to keep back skin partitioning and contamination of operative site>to avoid accumulation of moisture at the operative sitewhich whitethorn lead to skin breakdown>to prevent bacteria retain in operative site at heart 8 hours of nursing intervention the pt be equal to(p) manifest the followinga. ) intact suturesb. ) dry and intact wound dressingc. ) participation in passive ROM exercises>military rating was not carried out receivable to time constraints. Pt was endorsed to succeeding members of the health team up for further focussing and military rating Cues Nursing Diagnosis Scientific Explanation Objectives/Plan of Care Nursing Interventions Rationale paygrade S>Hindi namn ako nilalagnat verbalized by the patientO> v/s taken as followBPone hundred ten/80 mmHgRR22 cpmPR68 bpmT 37. C> S/P Appendectomy>with dry intact dressing on the surgical si te Risk for infection related to tissue trauma Inflammation of the appendixvAcute AppendicitisvAppendectomyvTissue trauma on RLQ abdomenMay provide admittance of entry for pathogens through>unnecessary exposure of surgical site> brusque aseptic techniques especially in wound dressing>contract with pts, SOs and visitors detention or other partsvMay expiry to infection Within 8 hours of nursing intervention the pt will be able verbalize ways in preventing infection/contamination specifically appropriate drop dead washing, and proper wound tuition as evidenced by>maintain enduring v/s> darling skin integrity>absence of swelling redness and infliction on operative site >Monitor v/s and record>assess operative site for signs of infection>change linens as necessary>Provide regular dressing care>Instruct pt and SOs to refrain from touching/scratching operative site>Encourage pt to verbalized any changes noted on operative site such as redness, swelling and u nusual/odorous drainage >Encourage pt to engage early ambulation and defy SOs assist him in such activities>Administer Penicillin G Sodium(antibiotic) as ordered > meridian in judge whitethorn signal infection>to provide baseline data for comparison and identify need for further management>to prevent growth of microorganisms on linens and beds> to prevent unnecessary exposure and contamination of operative sitewhich may delay wound healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to allow continuous monitoring and judicial decision of pt. educate>to promote circulation to the surgical site for timely healing>serve as prophylactic treatment and prevent bacteria to harbor on operative siteWithin 8 hours of nursing intervention the pt will be able verbalize ways in reventing infection/contamination specifically proper hand washing, and proper wound care as evidenced by>maintain stable v/s>good skin integrity> absence of swelling redness and offend on operative site>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago metropolis Cues Nursing Diagnosis Scientific Explanation Objectives/Plan of Care Nursing Interventions Rationale Evaluation S> Masakit ditto sa baba, while pointing at RLQ of abdomen. >rated pain as 5 on a scale of 10, where 1 as the lowest and 10 as the highest>characterized pain as tool>reported that pain occurs everytime when pt moves or movedO> v/s taken as followsT 37. CRR 21 cpmPR 64 bpmBP 120/70 mmHg> S/PAppendectomy>with dry intact dressing on the surgical site>with guarding way over the site>facial grimacing Acute pain related to tissue damage 2nd to punt appendectomy Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abd ominal tissuesvDisruption of skin surface and destruction of skin layersvActivation of nociceptors in dermis and tissuesvReceptors send impulses to systema nervosum centrale for interpretationvPain PerceptionvAcute Pain Within 6-8 hours of nursing intervention, the pt will be able to manifest might to screw with incompletely alleviate pain as evidenced bya. ) verbalization of fall pain reverberate 5/10 to 2/10b. engagement in diversional activities such as socialization, ceremonial occasion TV, and listening evaporate medical specialty >Monitor V/S and record>Assess pain characteristics including location, intensity, and frequence>Assess surgical site for swelling, redness or loose sutures>Promote adequate rest periods by temporarily limiting bodily function>Encourage pt to verbalize pain perception>Provide pt with diversional activities such as socialization, watch TV, and listening mellow music>Encourage SOs to rest provision of diversional activities an d a quiet environment >Administer Toradol (analgesic)as ordered >Elevation in rates suggest increased pain intensity and frequency>Elevation in intensity and frequency may indicate worsening condition>Swelling, redness , and loose sutures may contribute to the pain felt by pt. nd are indicative of further management>to lessen pain felt aggravated by movements>to allow further assessment of pain characteristics and evaluation of treatment / intervention>to help pt turn his attention to other matters than pain felt>to allow pt continue divert his attention>to relieved or lessen pain by inhibiting prostaglandin synthesis Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 0/10b. ) engagement in diversional activities such as socialization, watching TV, and listening mellow music>verbal report that pain is completely releived>abs ence of facial grimacing upon performance of activities such as changing position, sitting ,standing and walking> absence of guarding behavior over surgical site>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluationNursing DiagnosisCues Nursing Diagnosis Scientific Explanation Objectives/Plan of Care Nursing Interventions Rationale Evaluation S> Hindi pa masyado magaling ang sugat ko as verbalized by the patientO> S/P Appendectomy>with surgical incision at right lower abdominal area>with dry intact dressing on the surgical site Impaired Skin Integrity related to skin/tissue trauma Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvImpaired skin/tissue integrityWithin 8 hours of nursing intervention the pt will be able to manifest the followinga. ) intact suturesb. ) dry and intact wound dressingc. ) participation in passive ROM exercises >Assess operative site for redness, swelling, loose sutures, or soaked dressing>Monitor Vital Signs>Assist in passive movements(while 8hrs. lat on bed) such as bed turning and passive ROM exercise and active exercise thereafter movements such as bed position, sitting, standing, walking> Support incision as in splinting when coughing and during movement>Encourage pt to verbalized his for any untoward feelings especially pain, discomfort as well as changes noted on operative site>Encourage pt to engage early ambulation and have SOs assist him in such activities>Instruct pt and SOs to immediately report when dressing are soaked>Instruct pt and SOs to refrain from touching/scratching operative site>Provide regular dressing care>Administer Chlorampenicol Sodium(antibiotic) as ordered >to check skin integrity, monitor progress of healing and identify need for further> Serve as baseline data& gtto promote circulation to the surgical site for timely healing>to reduce pressure on the operative site>to allow continuous monitoring and assessment of pt. ondition>to promote circulation to the surgical site for timely healing>to promote circulation to the surgical site for timely healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to avoid accumulation of moisture at the operative sitewhich may lead to skin breakdown>to prevent bacteria harbor in operative siteWithin 8 hours of nursing intervention the pt be able manifest the followinga. ) intact suturesb. ) dry and intact wound dressingc. ) participation in passive ROM exercises>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation Cues Nursing Diagnosis Scientific Explanation Objectives/Plan of Care Nursing Interventions Rationale Evaluation S>Hindi namn ako nilalagnat verbalized by the patientO> v/s taken as followBP110/80 mmHgRR22 cpmPR68 bpmT 37. C> S/P Appendectomy>with dry intact dressing on the surgical site Risk for infection related to tissue trauma Inflammation of the appendixvAcute AppendicitisvAppendectomyvTissue trauma on RLQ abdomenMay provide portal of entry for pathogens through>unnecessary exposure of surgical site>inadequate aseptic techniques especially in wound dressing>contract with pts, SOs and visitors hands or other partsvMay result to infection Within 8 hours of nursing intervention the pt will be able verbalize ways in preventing infection/contamination specifically proper hand washing, and proper wound care as evidenced by>maintain stable v/s>good skin integrity>absence of swelling redness and pain on operative site >Monitor v/s and record>assess operative site for signs of infection>change linens as necessary>Provide regular dressing care>Instruct pt and SOs to refrain from touching/scratchin g operative site>Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage >Encourage pt to engage early ambulation and have SOs assist him in such activities>Administer Penicillin G Sodium(antibiotic) as ordered >Elevation in rates may signal infection>to provide baseline data for comparison and identify need for further management>to prevent growth of microorganisms on linens and beds> to prevent unnecessary exposure and contamination of operative sitewhich may delay wound healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to allow continuous monitoring and assessment of pt. condition>to promote circulation to the surgical site for timely healing>serve as prophylactic treatment and prevent bacteria to harbor on operative siteWithin 8 hours of nursing intervention the pt will be able verbalize ways in reventing infection/contamination specifically proper ha nd washing, and proper wound care as evidenced by>maintain stable v/s>good skin integrity>absence of swelling redness and pain on operative site>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago City Cues Nursing Diagnosis Scientific Explanation Objectives/Plan of Care Nursing Interventions Rationale Evaluation S> Masakit ditto sa baba, while pointing at RLQ of abdomen. >rated pain as 5 on a scale of 10, where 1 as the lowest and 10 as the highest>characterized pain as pricking>reported that pain occurs everytime when pt moves or movedO> v/s taken as followsT 37. CRR 21 cpmPR 64 bpmBP 120/70 mmHg> S/PAppendectomy>with dry intact dressing on the surgical site>with guarding behavior over the site>facial grimacing Acute pain related to tissue damage 2nd to post appendecto my Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvActivation of nociceptors in dermis and tissuesvReceptors send impulses to CNS for interpretationvPain PerceptionvAcute Pain Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 2/10b. engagement in diversional activities such as socialization, watching TV, and listening mellow music >Monitor V/S and record>Assess pain characteristics including location, intensity, and frequency>Assess surgical site for swelling, redness or loose sutures>Promote adequate rest periods by temporarily limiting activity>Encourage pt to verbalize pain perception>Provide pt with diversional activities such as socialization, watching TV, and listening mellow music>Encourage SOs to continue provision of diversional activities and a quiet environment >Administer Toradol (analgesic)as ordered >Elevation in rates suggest increased pain intensity and frequency>Elevation in intensity and frequency may indicate worsening condition>Swelling, redness , and loose sutures may contribute to the pain felt by pt. nd are indicative of further management>to lessen pain felt aggravated by movements>to allow further assessment of pain characteristics and evaluation of treatment / intervention>to help pt divert his attention to other matters than pain felt>to allow pt continue divert his attention>to relieved or lessen pain by inhibiting prostaglandin synthesis Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 0/10b. ) engagement in diversional activities such as socialization, watching TV, and listening mellow music>verbal report that pain is completely releived>absence of facial grimacing upon performance of activities such as changing position, sitting ,standing and walking> absence of guarding behavior over surgical site>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation