TRINIDAD, ALYSSA ANGELA A.

ASSESSMENT NURSING DIAGNOSIS Acute pain related to inflamed tissues. INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Masakit po pag bumabangon ako as verbalized by the patient while pointing at his incision site. Objective: Facial mask of pain Guarding behavior V/S taken as follows: Bp: 100/70 T: 37.8 P: 80 RR: 18

Inflammation of the appendix

Acute appendicitis

Appendectomy

After 8 hours of nursing intervention patient will report that pain is relieved and controlled, will appear relaxed and will be able to sleep and rest appropriately.

Independent 1. Assess the type of pain, noting location, characteristics and severity using the pain scale of 010. 1. Useful in monitoring effectiveness of medication, progression of healing and preventing complications. 2. Reduces abdominal distention, thereby reduces tension in the RLQ area 3. Helpful in keeping the patients tissue and muscles relaxed and relieved.

After 8 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort

Surgical wound will trigger activation of nociceptors from the tissues and will send impulses to the brain

2. Keep at rest in semi-fowlers position.

Pain will be perceived by the CNS causing

3. Provide comfort measures like back rubs and warm compress

ACUTE PAIN

Dependent 1. Administer analgesics as ordered 1. Acts as a prophylactic in order to relieve pain

ASSESSMENT

NURSING DIAGNOSIS Risk for infection related to postoperative incision.

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Inflammation of the appendix

Acute Appendicitis

Appendectomy

Tissue trauma on RLQ abdomen may provide portal of entry for pathogens through: Unnecessary exposure of the surgical site Inadequate aseptic techniques especially in wound dressing Contact with patients SOs and visitors

After 8 hours of nursing intervention, the patient and his SOs will identify the risk factors that could be present and have partial understanding about its control and will finally be free from any signs and symptoms related to infection.

Independent: 1.Identify the risk factors for possible occurrence of infection in the incision 2. Render health teachings especially in identification of environmental risk factors that could add up on infection. 1. To help the patient identify the present risk factors that may cause infection 2. To help the client modify, change or avoid some of the environmental factors present which could reduce the incidence of infection. 3. Monitoring patients vital signs could detect any early signs of infection

After 8 hours of nursing intervention, the patient was able to meet the goals with an evidence of the absence of the signs and symptoms related to infection.

3. Monitor Vital Signs

Dependent 1. Administer antibiotics as ordered 1. Antibiotics will help kill and stop the proliferation and growth of the bacteria which could cause infection.

Collaborative 1. Assist client in early ambulation 1. Promotes normalization of organ function thus promote wound healing.

May result to infection

ASSESSMENT O>-disruption of skin surface -destruction f skin layers

NURSING DIAGNOSIS Impaired skin integrity related to post surgery of the abdomen as evidenced by sutures in the abdominal area.

INFERENCE

PLANNING Goal: By the end of the shift, the client will develop and maintain optimal conditions for wound healing. Objectives: 1. After 30 minutes, the nurse will be able to assess the extent of involvement or injury. 2. After the shift, the nurse will be able to assist the client with correcting and minimizing condition and promote optimal healing of wound

INTERVENTION

RATIONALE

EVALUATION

Situation analysis: Impaired skin integrity was due to the clients tissue trauma on the surgical incision site from his recent surgery caused by small bowel obstruction. Health Implication: The skin is a barrier to infectious agents; however, any break in the skin can readily serve as a portal of entry putting the individual at risk for potential infections. (Fundamentals of Nursing by Kozier, et.al., 7th edition, page 633)

1. Note skin color, texture, and turgor. 2. Palpate skin lesions for size, shape, consistency, texture, temperature, and hydration. 3. Determine degree or depth of injury or damage to skin. 4. Measure length, width, depth of wound. 5. Inspect surrounding skin for erythema, induration, and maceration. 6. Note odors emitted from the wound. 1. Inspect skin, describing wound characteristics and changes observed. 2. Remeasure wound and observe for complications.

-To document status and provide baseline for future comparisons. NANDA 11th Edi. p. 620-62 -To monitor progress of wound healing. NANDA 11th Edi. p. 621 -To protect the wound and surrounding tissues. NANDA 11th Edi. p. 622 -Promotes circulation and reduces risks associated with immobility. NANDA 11th Edi. p. 622

The client developed and maintained optimal conditions for wound healing as evidenced by responses to interventions and teaching and actions performed and gradual healing of his wound.

3. Use appropriate dressings, wound coverings, drainage appliances for open or

draining wounds. 4. Encourage early ambulation.