Diagnosis: Risk for infection related to broken skin or traumatized tissue Intervention 1.

Prepare operative site according to specific procedure 2. Examine skin for breaks or irritation, signs of infection Rationale Minimizes bacterial counts and operative sites Disruption of skin integrity at or near the operative sites are sources of contamination to the incision 3. Identify breaks in aseptic technique and Contamination by environmental/personnel resolve immediately on occurrence contact renders the sterile field unsterile, thereby increasing the risk for infection 4. Apply sterile dressing Prevents environmental contamination of fresh wound 5. Administer antibiotics as indicated May be given prophylactically for suspected infection or contamination

Diagnosis: Acute pain related to disruption of the skin. Intervention 1. Provide information about transitory nature of discomfort, as appropriate 2. Reposition as indicated e.g.,semiFowlers position 3. Provide additional comfort measures Rationale Understanding the cause of the discomfort provides emotional reassuarance May relieve pain and enhances circulation.

Improve circulation, reduces muscle tension and anxiety associated with pain. 4. Encourage use of relaxation technique Relieves muscle and emotional tension; enhances sense of control and may improve coping abilities 5. Provide oral care, occasional ice Reduces discomfort associated with dry chips/sips of fluid as tolerated mucous membranes due to anesthetic agents, oral restrictions.

S O A P

Dili man ko kabalo mulimpyo sa akong inoperahan, mahadlok man gani ko mutan-aw., as verbalized by the client. Facial expression (confused) Risk for infection related to broken skin or traumatized tissue Long term: At the end of 4 days the patient will be able to learn how to maintain the incision site clean. Short term: At the end of 2 hours the patient will be able to learn how to clean the incision site. 1. Prepared operative site according to specific procedure. 2. Examined skin for breaks or irritation, signs of infection. 3. Identified breaks in aseptic technique and resolve immediately on occurrence. 4. Applied sterile dressing. 5. Administered antibiotics as indicated. At the end of 2 hours the patient was able to learn how to clean and how to maintain the incision site clean.

Diagnosis: Acute pain related to disruption of the skin. S O A P I kung mutukar na gani ang kasakit grabe jud,murag dili jud nako makaya., as verbalized by the client. Facial grimace Making a fist Reports of pain Acute pain related to disruption of the skin. Long term: At the end of 2 days the pain felt by the client will be lessen. Short term: At the end of 4 hours the pain felt by the client will be alleviated. 6. Provided information about transitory nature of discomfort, as appropriate. 7. Repositioned as indicated e.g.,semi-Fowlers position. 8. Provided additional comfort measures. 9. Encouraged use of relaxation technique. 10. Provided oral care, occasional ice chips/sips of fluid as tolerated. At the end of 2 hours the pain felt by the client was alleviated.

XI.

Health Teaching Prior to patient sent at OR, patient and the significant others was encourage to do the following simple exercises after one day: Encourage the patient to change position every 30 minutes - this is to prevent pulmonary complication such as pneumonia if patient can handle herself, encourage the patient to ambulate - to promote proper blood circulation - to increase energy requirements to perform activities of daily living The patient was encouraged to have the following diet: increase protein intake such foods like meat, fruits and egg - this is to promote wound healing increase intake of fruits and vegetables such as papaya, monggo, cabbage - this is to promote roughage in the body in order to avoid constipation The significant others and the patient was encouraged to do the following treatment after the operation: If patient will have fever - do the tepid sponge bath and afterwards check the temp heat losses will occur as skin and mucous membranes are exposed to cool environment temperature - give patient antipyretic medication this is to lower the patients temperature - encouraged the patient to increase fluid intake it aids and help to mobilize internal heat from the body through water - do wound dressing

Exercise

Diet

Treatment

Medications

this is to promote proper wound healing and will decrease the multiplication of the microorganisms The patient and the significant others of the patient was encouraged to let the patient take her medications religiously, medications such as: - Tramadol - Ketorolac - Ranitidine - Metoclopramide - Nubain