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Assessment S> Di pa masyadong magaling yung sugat ko galing operasyon. As verbalized by the patient.

O> Received patient lying on bed, awake, afebrile, with colostomy at LUQ of abdomen, with surgical incision at lower abdomen , with IVF of PNSS set to KVO VS: BP>110/70 mmHg RR>17 PR>63 Temp> 35.0C

Diagnosis Risk for infection related to disruption in the continuity of primary defences.

Rationale The patient has an incision at his abdominal area, and he also has a colostomy attached to him, meaning there are openings on his skin, which makes the primary defence of the body compromised which increases the risk of the patient to have infection.

Planning After 8 hours of nursing intervention, the patient will be free of signs of infection such as fever and purulent discharge at incision site.

Intervention - Assess patients general condition - Monitor vital signs, particularly temperature. - Observe skin condition for signs of infection, like redness, swelling, purulent discharge - Maintained proper aseptic technique at all times while handling the patient - Stress to the patient and guardians that proper aseptic technique must be observed when handling the incision site and colostomy site - Patient and guardian education about aseptic technique.

Evaluation After 8 hours of nursing intervention, the patient was free of signs of infection such as fever and purulent discharge.

Assessment S>May mga panahon na kumikirot yung sugat ko, minsan nasa 5-6/10 siya at minsan hindi naman ganun kasakit. As verbalized by the patient. O> Received patient lying on bed, awake, afebrile, with colostomy at LUQ of abdomen, with surgical incision at lower abdomen , with IVF of PNSS set to KVO, patient tries positions to alleviate pain VS:

Diagnosis Acute pain related to disruption of skin integrity secondary to operative procedure: Exploratory laparotomy with left hemicolectomy, transverse colostomy.

Rationale Surgical incisions are a form of trauma, and this trauma irritates the nerve endings that are affected so the brain perceives it as pain.

Planning After 8 hours of nursing intervention, the patient will report that pain is controlled, pain scale will decrease from 5-6 to tolerable levels.

Intervention - Assess patients general condition - Monitor vital signs, particularly temperature. - Assess pain scale and characteristic - Provide comfort measures such as repositioning, use of hot/cold compress - Encourage use of relaxation techniques such as focused breathing, watching tv - Assist in administering pain medications

Evaluation After 8 hours of nursing intervention, the patient has reported that pain is controlled.

BP>110/70 mmHg RR>17 PR>63 Temp> 35.0C

Assessment S>Sa ngayon kailangan ko parin ng tulong gumalaw at gawin ang iba kong Gawain, medyo nanghihina pa ako at masakit pa yung sugat ko. As verbalized by the patient. O> Received patient lying on bed, awake, afebrile, with colostomy at LUQ of abdomen, with surgical incision at lower

Diagnosis Activity intolerance related to bed rest secondary to pain and body weakness.

Rationale Surgical incisions are a form of trauma, and this trauma irritates the nerve endings that are affected so the brain perceives it as pain. And that pain could also contribute to the fact that the patient is intolerant in doing activities on his own.

Planning After 8 hours of nursing intervention, the patient will report a measurable increase in activity tolerance.

Intervention - Assess patients general condition - Monitor vital signs. - Assess pain scale and characteristic - Provide comfort measures such as repositioning, use of hot/cold compress - Encourage use of relaxation techniques such as focused breathing, watching tv - Assist in administering pain medications - Adjust patients daily activities. - Gradually increase activity/exercise gradually - Assist in doing

Evaluation After 8 hours of nursing intervention, the patient has maintained current activity tolerance level.

abdomen , with IVF of PNSS set to KVO, patient uses slow movements and is assisted by guardian, activity intolerance level 1 VS: BP>110/70 mmHg RR>17 PR>63 Temp> 35.0C

range of motion exercises