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HEALTH HISTORY:
Admission chief complain and history of present illness:
Male patient 27 year old admitted to surgical ward in basma hospital from clinic .
patient work in store and before three days ago patient was carry a heavy boxes
,when he carry boxes he felt a sharp and sudden pain in inguinal area this lead to fall
down the boxes .then when patient go to his home he felt this pain again when he
carry television this lead patient to go to doctor yesterday then doctor was admit
patient to hospital as case of right inguinal hernia and decide surgical to repair hernia
.
No chronic illness but patient left leg was broken before 13 year ago when he
was play football . no past surgical or hospitalization
PHYSICAL EXAMINATION:
0General appearance:
0Pulse rate: 68 B/M Temperature: 37.2 cº
1Respiratory System:
5renal system:
7abdomen :
9Diagnostic test :
Num Name Range Normal range Nursing
note
1 Glucose 5 mmol/l 4.2-6.4 mmol/L Normal
Nursing Assessment :
Subjective data:
Patient said : I feel pain in surgical area in right side not
radiate to left side relief by supine position increase by
coughing, walking and setting (pain scale 6 from 10 ).
Objective data:
0Pulse rate: 68 B/M Temperature: 37.2ºc
Nursing Diagnoses :
Nursing Diagnoses 1:
Planning :
Nursing Interventions :
Have the patient splint the incision site with hand or pillow when
coughing to lessen pain and protect site from increased intraabdominal
pressure. Splinting and proper positing reduce the stress on the
incision area.
Evaluation :
Goal met . patient now in general condition free from verbalization of pain and
he said the scale of pain now is 3 from 10
Nursing Diagnoses 2 :
Planning :
Nursing Interventions :
- Allow the client legs to dangle first; support him from the side
because Dangling the legs helps minimize orthostatic
hypotension.
Evaluation :
Nursing Diagnoses 3 :
Planning :
Nursing Interventions :
Evaluation :
Goal not met because wound healing need more than one shift care to maintain
skin integrity
Nursing Diagnoses 4 :
Planning :
Nursing Interventions :
Evaluation :
Goal met
Nursing Diagnoses 5 :
Planning :
.Nursing Interventions :
Check dressing for drainage and incision for redness and swelling.
Monitor for other signs/symptoms of infection: fever, chills, malaise,
diaphoresis.
Administer antibiotics as order
Evaluation :
Hani alzo3bi