PATIENT INFORMATION

Name: MMP NAME ALERT? Y N Age: Gender: F DOA: 07/16/2012 Chief Complaint: Abnormal Uterine Bleeding Diagnosis: Adenomyosis with Adenomyoma Role: Wife Family Support: Husband and three children SUBJECTIVE DATA Im experiencing pain 7 out of 10 (Nakakaramdam ako ng sakitmga 7 out of 10) OBJECTIVE DATA Facial Grimace Guarding Behavior Irritability Presence of abdominal incision BP 160/90; HR 92; RR - 20 Prolonged supine position DIAGNOSTICS Hgb 98 g/L Hct 0.32

NURSING DX/PROBLEM Acute pain related to abdominal incision secondary to surgical procedure

EXPECTED OUTCOME After the nursing interventions within 8hours, the client will verbalize reduction in pain from 7 to 5.

INTERVENTIONS
Administer analgesics as ordered. Implement nonpharmacological strategies such as relaxation techniques, and distraction Assess effectiveness of interventions to relieve pain. Encourage adequate rest periods Monitor surgical site for signs and symptoms of infection: redness/discoloration, swelling, purulent drainage, heat and increased pain. Monitor clients temperature Administer antibiotics as ordered Encourage adequate nutritional intake especially of protein, vit C and iron. Monitor for signs and symptoms of UTI Encourage leg exercises Use antiembolic stockings Encourage ambulation as soon as possible according to physicians order Administer IV fluids; encourage increase in fluid intake as prescribed Administer 1 unit Packed RBC and 1 unit PWB, as ordered.

NURSING 2 DX/PROBLEM Impaired skin Integrity related to surgical procedure. EXPECTED OUTCOME After the nursing interventions within the 8hours shift, the clients surgical site will have no purulent drainage or heat and will remain afebrile.

NURSING DX/PROBLEM Risk for Ineffective Peripheral Tissue perfusion related to prolonged time in operating room EXPECTED OUTCOME After the nursing interventions within 8-hours shift, the patient will remain free of thrombophlebitis and DVT, as evidenced by absence of calf pain NURSING DX/PROBLEM Risk for Infection related to decreased hemoglobin and tissue destruction EXPECTED OUTCOME After the nursing interventions within 8-hour shift, the patient will achieve timely wound healing as evidenced by free of purulent drainage or erythema and afebrile.

TEACHING
Relaxation technique Teach patient to splint abdomen when moving or coughing with a pillow. Deep Breathing Techniques Guidelines for resuming normal activity

Drug Administration Reporting of symptoms

PHARMACOLOGY
Ketorolac 30mg TIV q8h Ceftriaxone 1g TIV q12h D5LR 1L x 35gtts/min

INTERDISCIPLINARY NOTES (PDAR) Date and Time NOTES