Francisco, John Eric Daryl V.

BN 40 free

Cues

Nursing Diagnosis Impaired Skin Integrity related to skin/tissue trauma

Scientific Explanation Inflammation of the appendix Acute Appendicitis Appendectomy Dissection if right lower abdominal tissues Disruption of skin surface and destruction of skin layers Impaired skin/tissue integrity

Objectives/Plan of Care Short term objectives: Within 8 hours of nursing intervention the pt will be able to manifest the following: a.) intact sutures b.) dry and intact wound dressing c.) participation in passive ROM exercises Long term objectives: Within 3 days of nursing intervention the pt will be able to manifest the following: a.) intact sutures b.) dry and intact wound dressing c.)participating in ADL.

Nursing Interventions

Rationale

Evaluation

O> Appendectomy >with surgical incision at right lower abdominal area >with wet dressing and not intact on the surgical site

Independent: >Assess operative site for redness, swelling, loose sutures, or soaked dressing

>to check skin integrity, monitor progress of healing and identify need for further > Serve as baseline data >to promote circulation to the surgical site for timely healing

>Monitor Vital Signs >Assist in passive movements(while 8hrs. flat on bed) such as bed turning and passive ROM exercise and active exercise thereafter movements such as bed position, sitting, standing, walking

Short term objectives: Within 8 hours of nursing intervention the pt be able manifest the following: a.) intact sutures b.) dry and intact wound dressing c.) 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 Long term objectives:

>to reduce pressure on > Support incision as in splinting the operative site when coughing and during movement >to allow continuous >Encourage pt to verbalized his for monitoring and any untoward feelings especially assessment of pt. pain, discomfort as well as changes condition noted on operative site >to avoid accumulation >Provide regular dressing care of moisture at the operative site which may lead to skin breakdown

Collaborative: >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

>to promote circulation to the surgical site for timely healing

>for immediate replacement to prevent skin breakdown and contamination of operative site >to prevent bacteria harbor in operative site

Within 3 days of nursing intervention the pt will be able to manifest the following: a.) intact sutures b.) dry and intact wound dressing c.)participating in ADL. >evaluation was cleared to the pt and he is ready for home care /self care

Dependent: >Administer antibiotic as ordered

Cues

Nursing Diagnosis

Scientific Explanation Inflammation of the appendix Acute Appendicitis Appendectomy Tissue trauma on RLQ abdomen May 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 parts May result to infection

Objectives/Plan of Care Nursing Interventions Short term objectives: Within 1 hour of nursing intervention the pt will be able verbalize ways in preventing infection/contamination specifically proper hand washing, and proper wound care to obtain: >maintain stable v/s >good skin integrity >absence of swelling redness and pain on operative site Long term objectives: Within 3 days of nursing intervention the pt will be able to promote wellness to prevent infection specifically teaching to the patient: > good skin integrity > absence of swelling redness and pain on operative site >the pt knows how to Independent: >Monitor v/s and record

Rationale

Evaluation

O> v/s taken as follow: BP:100/70 mmHg RR:24 cpm PR:78 bpm T: 36.9 C > S/P Appendectomy >with wet dresssing and not intact on the surgical site

Risk for infection related to tissue trauma

>Elevation in rates may signal infection

>assess operative site for signs of 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 site which may delay wound healing >for immediate replacement to prevent skin breakdown and contamination of operative site

>change linens as necessary

>Provide regular dressing care

>Instruct pt and SOs to refrain from touching/scratching operative site

Short term objectives: 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 >Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation Long term objectives: Within 3 days of nursing intervention the pt will be able to promote wellness to

>Encourage pt to

manage techniques and preventive measures for infection

verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage Collaborative: >Encourage pt to engage early ambulation and have SOs assist him in such activities Dependent >Administer antiinflamatory or antibiotic drugs as ordered

>to allow continuous monitoring and assessment of pt. condition

>to promote circulation to the surgical site for timely healing

prevent infection specifically teaching to the patient: > good skin integrity > absence of swelling redness and pain on operative site >the pt knows how to manage techniques and preventive measures for infection >evaluation was cleared to the pt and he is ready for home care /self care

>serve as treatment and prevent bacteria to harbor on operative site

Cues

Nursing Diagnosis

Scientific Explanation Inflammation of the appendix Acute Appendicitis Appendectomy Dissection if right lower abdominal tissues Disruption of skin surface and destruction of skin layers Activation of nociceptors in dermis and tissues Receptors send impulses to CNS for interpretation Pain Perception Acute Pain

Objectives/Plan of Care Short term objectives: Within 2-3 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced by a. ) verbalization of decrease pain form 5/10 to 2/10 b.) engagement in diversional activities such as socialization, watching TV, and listening mellow music

Nursing Interventions Independent: >Monitor V/S and record

Rationale

Evaluation Short Term Objectives: Within 2-3 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced by a. ) verbalization of decrease pain form 5/10 to 0/10 b.) 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

O> v/s taken as follows T: 36.9 C RR: 24 cpm PR: 78 bpm BP: 100/70 mmHg > S/P Appendectomy >with wet and not intact dressing on the surgical site >with guarding behavior over the site >facial grimacing

Acute pain related to tissue damage 2nd to post appendectomy

>Elevation in rates suggest increased pain intensity and frequency >Elevation in intensity and frequency may indicate worsening condition

>Assess pain characteristics including location, intensity, and frequency >Assess surgical site for swelling, redness or loose sutures

long term objectives: After 3 days of nursing intervention a.) the patient will report absence of >Encourage pt to pain verbalize pain b.)appears relaxed perception able to rest/sleep c.)participate in ADL

>Promote adequate rest periods by temporarily limiting activity

>Swelling, redness , and loose sutures may contribute to the pain felt by pt. and are indicative of further management >to lessen pain felt aggravated by movements

>to allow further assessment of pain characteristics and evaluation of

Collaborative: >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 Dependent Administer analgesics,as indicated,to maximum dosage,as needed.

treatment / intervention

>to help pt divert his attention to other matters than pain felt

>to allow pt continue divert his attention

>to realieved pain and to emphasized patient need of pharmacological medicine

>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation Long term objectives: After 3 days of nursing intervention a.) the patient will report absence of pain b.)appears relaxed able to rest/sleep c.)participate in ADL >knows how to manage himself physically and emotionally >evaluation was cleared to the pt and he is ready for home care /self care