ASSESSM ANALYSIS RATIONALE PLANNIN INTERVENTION RATIONALE EVALUATI

ENT G ON

S> “ Hindi Impaired Due to the After the 8 >Assess operative >to check skin After the
pa Skin surgical hours site for integrity, monitor series
masyado Integrity procedure of nursing redness, swelling, progress of healing of nursing
magaling related to (appendecto interventio loose and identify need interventio
ang skin/tissue my) as n the sutures, or soaked for further n the goal
sugat ko” trauma as management client will dressing has been
as evidenced to acute be able > Serve as baseline met as
verbalized by the appendicitis, to data manifested
by surgical an incision at manifest by the
the patient incision at right lower the >Monitor Vital Signs >to promote following:
right lower abdominal following: circulation to the a.) intact
O> S/P abdominal area is made a.) intact surgical site for sutures
Appendect area due to causing the sutures >Assist in passive timely healing b.) dry and
o appendecto disruption of b.) dry and movements(while intact
my my skin surface intact 8hrs. flat wound
>with and its wound on bed) such as bed dressing
surgical integrity. dressing turning c.)
incision at c.) and passive ROM participatio
right lower participati exercise n
abdominal on and active exercise in passive
area in passive thereafter ROM
ROM movements such as >to allow exercises
exercises bed continuous
position, sitting, monitoring and
standing, assessment of pt.
walking condition

>Encourage pt to
verbalized
his for any untoward
feelings >to promote
especially pain, circulation to the
discomfort as surgical site for
well as changes timely healing
noted on
operative site >to promote
circulation to the
>Encourage pt to surgical site for
engage timely healing
early ambulation and
have >for immediate
SO’s assist him in replacement to
such prevent skin
activities breakdown and
contamination of
>Instruct pt and SO’s operative site
to
immediately report >to avoid
when accumulation of
dressing are soaked moisture at the
operative site
which may lead to
>Instruct pt and SO’s skin breakdown
to
refrain from >to prevent
touching/scratching bacteria harbor in
operative operative site
site

>Provide regular
dressing
care

>Administer
antibiotic therapy as
ordered
ASSESSM ANALYS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
ENT IS

S>”Hindi Risk for Due to the After the 8 >Monitor v/s and >Elevation in rates After the series
namn infection surgical hours of record may of
ako related procedure nursing signal infection nursing
nilalagnat” to (appendectom intervention >assess operative intervention the
verbalized tissue y) as the client site for signs of >to provide goal has been
by trauma management will be able infection baseline data met
the patient to acute verbalize for comparison and as evidenced by:
appendicitis, ways in identify need for >maintain stable
O> v/s an incision at preventing further v/s
taken as right lower infection/ >change linens as management >good skin
follow: abdominal contaminatio necessary integrity
area is made n specifically >to prevent growth >absence of
causing the proper hand of swelling redness
disruption of washing, and >Provide regular microorganisms on and pain on
skin surface proper wound dressing care linens and beds operative site
making it at care
risk for being as evidenced > to prevent
invaded by by: unnecessary
pathologic >maintain exposure and
organism stable >Instruct pt and contamination of
v/s SO’s to refrain operative site which
>good skin from touching/ may delay wound
integrity scratching healing
>absence of operative
swelling site >for immediate
redness and replacement to
pain on prevent skin
operative site >Encourage pt to breakdown and
verbalized any contamination of
changes operative site
>to allow
continuous
monitoring and
assessment of pt.
condition