Nursing Diagnosis

Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| S> â€Å" Hindi pa masyado magaling ang sugat ko† as verbalized by the patientO> S/P Appendectomy>with surgical incision at right lower abdominal area>with dry intact dressing on the surgical site| Impaired Skin Integrity related to skin/tissue trauma| Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvImpaired skin/tissue integrity|Within 8 hours of nursing intervention the pt will be able to manifest the following:a. ) intact suturesb. ) dry and intact wound dressingc. ) participation in passive ROM exercises| >Assess operative site for redness, swelling, loose sutures, or soaked dressing>Monitor Vital Signs>Assist in passive movements(while 8hrs. lat on bed) such as bed turning and passive ROM exercise and active exercise the reafter movements such as bed position, sitting, standing, walking> Support incision as in splinting when coughing and during movement>Encourage pt to verbalized his for any untoward feelings especially pain, discomfort as well as changes noted on operative site>Encourage pt to engage early ambulation and have SO’s assist him in such activities>Instruct pt and SO’s to immediately report when dressing are soaked>Instruct pt and SO’s to refrain from touching/scratching operative site>Provide regular dressing care>Administer Chlorampenicol Sodium(antibiotic) as ordered| >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>to reduce pressure on the operative site>to allow continuous monitoring and assessment of pt. ondition>to promote circulation to the surgical site for timely healing>to promote circulation to the surgical site for timely healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to avoid accumulation of moisture at the operative sitewhich may lead to skin breakdown>to prevent bacteria harbor in operative site|Within 8 hours of nursing intervention the pt be able manifest the following:a. ) intact suturesb. ) dry and intact wound dressingc. ) 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| Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| S>†Hindi namn ako nilalagnat† verbalized by the patientO> v/s taken as follow:BP:110/80 mmHgRR:22 cpmPR:68 bpmT: 37. C> S/P Appendectomy>with dry intact dressing on the surgical site| Risk for infection related to tissue trauma| Inflammation of the appen dixvAcute AppendicitisvAppendectomyvTissue trauma on RLQ abdomenMay provide portal of entry for pathogens through:>unnecessary exposure of surgical site>inadequate aseptic techniques especially in wound dressing>contract with pt’s, SO’s and visitors hands or other partsvMay result to infection| 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 | >Monitor v/s and record>assess operative site for signs of infection>change linens as necessary>Provide regular dressing care>Instruct pt and SO’s to refrain from touching/scratching operative site>Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage >Encourage pt to engage early ambulation an d have SO’s assist him in such activities>Administer Penicillin G Sodium(antibiotic) as ordered| >Elevation in rates may signal 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 sitewhich may delay wound healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to allow continuous monitoring and assessment of pt. condition>to promote circulation to the surgical site for timely healing>serve as prophylactic treatment and prevent bacteria to harbor on operative site|Within 8 hours of nursing intervention the pt will be able verbalize ways in reventing 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>Evalu ation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation| Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago City Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| S> â€Å"Masakit ditto sa baba†, while pointing at RLQ of abdomen. >rated pain as 5 on a scale of 10, where 1 as the lowest and 10 as the highest>characterized pain as pricking>reported that pain occurs everytime when pt moves or movedO> v/s taken as followsT: 37. CRR: 21 cpmPR: 64 bpmBP: 120/70 mmHg> S/PAppendectomy>with dry intact dressing on the surgical site>with guarding behavior over the site>facial grimacing| Acute pain related to tissue damage 2nd to post appendectomy| Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvActivation of nociceptors in dermis and tissuesvReceptors send impulses to CNS for interpretationvPain PerceptionvAcute Pain| Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 2/10b. engagement in diversional activities such as socialization, watching TV, and listening mellow music| >Monitor V/S and record>Assess pain characteristics including location, intensity, and frequency>Assess surgical site for swelling, redness or loose sutures>Promote adequate rest periods by temporarily limiting activity>Encourage pt to verbalize pain perception>Provide pt with diversional activities such as socialization, watching TV, and listening mellow music>Encourage SO’s to continue provision of diversional activities and a quiet environment >Administer Toradol (analgesic)as ordered | >El evation in rates suggest increased pain intensity and frequency>Elevation in intensity and frequency may indicate worsening condition>Swelling, redness , and loose sutures may contribute to the pain felt by pt. nd are indicative of further management>to lessen pain felt aggravated by movements>to allow further assessment of pain characteristics and evaluation of treatment / intervention>to help pt divert his attention to other matters than pain felt>to allow pt continue divert his attention>to relieved or lessen pain by inhibiting prostaglandin synthesis| Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 0/10b. ) 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>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation| Nursing Diagnosis Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| S> â€Å" Hindi pa masyado magaling ang sugat ko† as verbalized by the patientO> S/P Appendectomy>with surgical incision at right lower abdominal area>with dry intact dressing on the surgical site| Impaired Skin Integrity related to skin/tissue trauma| Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvImpaired skin/tissue integrity|Within 8 hours of nursing intervention the pt will be able to manifest the following:a. ) intact suturesb. ) dry and intact wound dressingc. ) participation in passive ROM exercises| >Assess operative site for redness, swelling, loose sutures, or soaked dressing>Monitor Vital Signs>Assist in passive movements(while 8hrs. lat on bed) such as bed turning and passive ROM exercise and active exercise the reafter movements such as bed position, sitting, standing, walking> Support incision as in splinting when coughing and during movement>Encourage pt to verbalized his for any untoward feelings especially pain, discomfort as well as changes noted on operative site>Encourage pt to engage early ambulation and have SO’s assist him in such activities>Instruct pt and SO’s to immediately report when dressing are soaked>Instruct pt and SO’s to refrain from touching/scratching operative site>Provide regular dressing care>Administer Chlorampenicol Sodium(antibiotic) as ordered| >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>to reduce pressure on the operative site>to allow continuous monitoring and assessment of pt. ondition>to promote circulation to the surgical site for timely healing>to promote circulation to the surgical site for timely healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to avoid accumulation of moisture at the operative sitewhich may lead to skin breakdown>to prevent bacteria harbor in operative site|Within 8 hours of nursing intervention the pt be able manifest the following:a. ) intact suturesb. ) dry and intact wound dressingc. ) 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| Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| S>†Hindi namn ako nilalagnat† verbalized by the patientO> v/s taken as follow:BP:110/80 mmHgRR:22 cpmPR:68 bpmT: 37. C> S/P Appendectomy>with dry intact dressing on the surgical site| Risk for infection related to tissue trauma| Inflammation of the appen dixvAcute AppendicitisvAppendectomyvTissue trauma on RLQ abdomenMay provide portal of entry for pathogens through:>unnecessary exposure of surgical site>inadequate aseptic techniques especially in wound dressing>contract with pt’s, SO’s and visitors hands or other partsvMay result to infection| 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 | >Monitor v/s and record>assess operative site for signs of infection>change linens as necessary>Provide regular dressing care>Instruct pt and SO’s to refrain from touching/scratching operative site>Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage >Encourage pt to engage early ambulation an d have SO’s assist him in such activities>Administer Penicillin G Sodium(antibiotic) as ordered| >Elevation in rates may signal 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 sitewhich may delay wound healing>for immediate replacement to prevent skin breakdown and contamination of operative site>to allow continuous monitoring and assessment of pt. condition>to promote circulation to the surgical site for timely healing>serve as prophylactic treatment and prevent bacteria to harbor on operative site|Within 8 hours of nursing intervention the pt will be able verbalize ways in reventing 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>Evalu ation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation| Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago City Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| S> â€Å"Masakit ditto sa baba†, while pointing at RLQ of abdomen. >rated pain as 5 on a scale of 10, where 1 as the lowest and 10 as the highest>characterized pain as pricking>reported that pain occurs everytime when pt moves or movedO> v/s taken as followsT: 37. CRR: 21 cpmPR: 64 bpmBP: 120/70 mmHg> S/PAppendectomy>with dry intact dressing on the surgical site>with guarding behavior over the site>facial grimacing| Acute pain related to tissue damage 2nd to post appendectomy| Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvActivation of nociceptors in dermis and tissuesvReceptors send impulses to CNS for interpretationvPain PerceptionvAcute Pain| Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 2/10b. engagement in diversional activities such as socialization, watching TV, and listening mellow music| >Monitor V/S and record>Assess pain characteristics including location, intensity, and frequency>Assess surgical site for swelling, redness or loose sutures>Promote adequate rest periods by temporarily limiting activity>Encourage pt to verbalize pain perception>Provide pt with diversional activities such as socialization, watching TV, and listening mellow music>Encourage SO’s to continue provision of diversional activities and a quiet environment >Administer Toradol (analgesic)as ordered | >El evation in rates suggest increased pain intensity and frequency>Elevation in intensity and frequency may indicate worsening condition>Swelling, redness , and loose sutures may contribute to the pain felt by pt. nd are indicative of further management>to lessen pain felt aggravated by movements>to allow further assessment of pain characteristics and evaluation of treatment / intervention>to help pt divert his attention to other matters than pain felt>to allow pt continue divert his attention>to relieved or lessen pain by inhibiting prostaglandin synthesis| Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 0/10b. ) 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>Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation|