PATIENT NAME: PATIENT X

AGE: 30 y/o
CASE NO. : 21924
DIAGNOSIS: Acute Appendicitis

NURSING
ASSESSMENT PLANNING
DIAGNOSIS

Subjective Data: Impaired skin / tissue integrity Within 8 hours of our shift,
related to mechanical interrup- immediate post operative
tion of the skin (presence of nursing care, the client
surgical wound) will manifest intact skin
Objective Data: integrity as evidenced by:
T: 36.4oC
RR: 18 b/m 1.) absence of inflamma-
PR: 80b/m tion, redness, purulent
BP: 120/80mmHg discharges on skin or
operative site
(+) Surgical incision
2.) vital signs will remain
No exudates, itchiness, and in normal range
redness noted.
 NURSING
RATIONALE EVALUATION
INTERVENTION
Goal Met
*Monitored vital signs. *To monitor patient's After 8 hours immediate post
progress. operative nursing care the
*Monitored intake and output. *To assess risk for hypo- client manifested intact
volemic shock. skin integrity as evidenced by:
*Inspected wound regularly, *Early recognition of
noting characteristics and delayed healing or deve- 1.) Absence of inflammation,
integrity. Note patients at loping complications may redness, purulent discharges
risk for delayed healing. prevent a more serious on skin or operative site
situation.
2.) Vital Signs remained in
normal range:
T: 37.1oC
RR: 18 b/m
PR: 99b/m
BP: 120/80mmHg