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Name: Patient D Date: June 28, 2008

Age: 32 Gender: Male Shift: 3-11


Diagnosis: S/P Appendectomy Ward: Private Room N3302

Nursing Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation


Problem
S:> “ Masakit dito sa Inflammation of the STO:> Within 8 hours of Dx:> Monitor v/s and > Elevation in rates suggest > The Pt. manifested
baba”, while pointing at appendix nursing intervention, the record. increased pain intensity ability to cope with
RLQ of abdomen. Pt. will manifest ability and frequency. incompletely relieved
> rated pain as 6 on a to cope with > Assess pain > Elevation in intensity and pain as evidenced by:
scale of 10, where 1 as Acute Appendicitis incompletely relieved characteristics including frequency may indicate a a.) verbalization of
the lowest and 10 as the pain as evidenced by: location, intensity, and worsening condition. decrease in pain from
highest. a.) verbalization of frequency. 6/10 to 4/10
> characterized pain as Appendectomy decrease in pain from > Assess surgical site > Swelling, redness, and b.) decreased RR from 23
pricking 6/10 to 2/10 for swelling, redness, or loose sutures may to 19 breaths per minute,
> reported that pain b.) RR will be decreased loose sutures. contribute to the pain felt while other v/s remained
occurs every time Pt. from 23 to 19 breaths per by the Pt, and are within normal range
moves or is moved Dissection of right minute, while other v/s indicative of further c.) engagement in
lower abdominal remain within normal management. diversional activities such
O:> v/s taken as follows: tissues range as socialization, watching
T= 37.0 C c.) engagement in Tx: > Provide Pt. with > To help Pt. divert his TV game shows, and
PR= 83 bpm diversional activities diversional activities attention to other matters listening to mellow music
RR= 23 breaths/min Disruption of skin such as socialization, such as socialization and other than the pain felt.
BP= 110/70 mmHg surface and destruction watching TV game watching TV game
> S/P appendectomy of skin layers shows, and listening to shows.
> with surgical incision mellow music > Promote adequate > To lessen pain felt
on RLQ of abdomen rest periods by aggravated by movements. > Evaluation was not
> facial grimacing Activation of temporarily limiting carried out due to time
upon movement nociceptors in the activity. constraints. Pt. was
> guarding behavior dermis and tissues > Administer Toradol > To relieve or lessen pain endorsed to succeeding
over surgical site LTO:> Within 3 days of (analgesic), as ordered. by inhibiting prostaglandin members of the health
nursing intervention, the synthesis. team for further
A:> Acute pain r/t Receptors send Pt. will manifest signs of management and
skin/tissue trauma impulses to CNS for completely relieved pain Edx:> Encourage Pt. to > To allow further evaluation.
interpretation as evidenced by: verbalize pain. assessment of pain
> verbal report that pain characteristics and
is completely relieved evaluation of treatment/
Pain perception > absence of facial interventions.
grimacing upon > Encourage SOs to > To allow Pt. to continue
performance of activities continue provision of to divert his attention to
Acute Pain such as changing diversional activities and other matters other than
position, sitting, a quiet environment. felt pain.
standing, and walking
> absence of guarding
behavior over surgical
site
Name: Patient D Date: June 28, 2008
Age: 32 Gender: Male Shift: 3-11
Diagnosis: S/P Appendectomy Ward: Private Room N3302

Nursing Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation


Problem
S:> “Hindi pa Inflammation of the STO: Dx: > Assess operative > To check for skin > The patient manifested
masyadong magaling appendix > Within 8 hours of site for redness, swelling, integrity, monitor progress the following:
tong sugat ko” as nursing intervention, the loose sutures, or soaked of healing, and identify a.) intact sutures
verbalized by the patient Pt. will manifest the dressings. need for further b.) dry and intact wound
Acute Appendicitis following: management. dressing
O: > S/P appendectomy a.) intact sutures Tx: > Provide regular > To avoid accumulation c.) participation in
> with surgical incision b.) dry and intact wound wound dressing. of moisture at the operative passive ROM exercises
at right lower abdominal Appendectomy dressing site that may lead to skin
area c.) participation in breakdown.
> with dry and intact passive ROM exercises > Assist in passive > To promote circulation to
dressing on the surgical movements (while flat on the surgical site for timely
site Dissection of right LTO: bed for 8 hours) such as healing. > Evaluation was not
lower abdominal > Within 3 days of bed turning and passive carried out due to time
A:> Impaired skin/tissue tissues nursing intervention the ROM exercises, and constraints. Pt. was
integrity related to Pt. and SOs will active (thereafter) endorsed to succeeding
skin/tissue trauma demonstrate: movements such as members of the health
Disruption of skin a.) proper aseptic wound changing bed position, team for further
surface and destruction care technique sitting, standing, and management and
of skin layers b.) proper supporting of walking. evaluation.
incision such as splinting > Support incision, > To reduce pressure on
c.) engagement in active as in splinting when the operative site.
Impaired skin/tissue movements such as coughing, and during
integrity sitting, standing, and movement.
walking > Administer > To prevent bacteria to
Zefocent (antibiotic), as harbor in the operative site
ordered. and hinder tissue/skin
healing, by inhibiting
bacterial cell wall
synthesis.
Edx:> Encourage Pt. to > To allow continuous
verbalize any untoward monitoring and assessment
feelings, esp. discomfort of Pt. condition.
or pain, as well as
changes noted on
operative site.
> Instruct Pt. and SOs > To prevent unnecessary
to refrain from exposure and
touching/scratching contamination of the
operative site. operative site which may
delay healing.
> Instruct Pt and SOs > For immediate
to immediately report replacement to prevent skin
when dressings are breakdown and
soaked. contamination of operative
site.
> Demonstrate to Pt. > To promote healing and
and SOs the proper way emphasize the importance
of giving wound care of aseptic techniques in
with emphasis on proper preventing
handwashing and aseptic infection/contamination of
techniques. operative site.
> Encourage Pt. to > To promote circulation at
engage in early operative site for timely
ambulation and have his healing.
SOs assist him in such
activities.
Name: Patient D Date: June 28, 2008
Age: 32 Gender: Male Shift: 3-11
Diagnosis: S/P Appendectomy Ward: Private Room N3302

Nursing Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation


Problem
O:> v/s taken as Inflammation of the STO: >Within 8 hours Dx:> Monitor v/s and > Elevation in rates may > The Pt. and SOs
follows: appendix of nursing intervention, record. signal infection. verbalized ways in
T= 37.0 C the Pt. and SOs will > Assess operative site > To provide baseline data preventing infection/
PR= 81 bpm verbalize ways in for signs of infection. for comparison. contamination,
RR= 23 breaths/min Acute Appendicitis preventing infection/ > To check for skin specifically proper
BP= 110/70 mmHg contamination, integrity and identify need handwashing, and proper
> S/P appendectomy specifically proper for further management. wound care.
> with dry and intact Appendectomy handwashing, and
dressing on RLQ of proper wound care. Tx: > Provide regular > To prevent growth of
abdomen wound dressing MOs on dressings.
Tissue trauma on RLQ aseptically.
LTO:> Within 3 days of > Change linens and > To prevent growth of > Evaluation was not
A:> Risk for infection nursing intervention, the Pt’s robes, as necessary. MOs on linens and robes. carried out due to time
r/t tissue trauma May provide portal of Pt. will maintain stable > Administer Zefocent > To prevent bacteria to constraints. Pt. was
entry for pathogens v/s and good skin (antibiotic), as ordered. harbor in the operative site endorsed to succeeding
through: integrity, characterized and hinder tissue/skin members of the health
> unnecessary exposure by absence of swelling, healing, by inhibiting team for further
of surgical site redness and pain on bacterial cell wall management and
> inadequate aseptic operative site. synthesis. evaluation.
techniques especially in
wound dressing Edx:> Encourage Pt. to > To allow continuous
> contact with Pt.’s, verbalize any changes monitoring and assessment
SOs’, and visitors’ hands noted on operative site of Pt. for signs of
or other body parts such as redness, swelling, infection.
and unusual/odorous
drainage on operative
site.
May result to infection > Instruct Pt. and SOs > To prevent
to refrain from contamination of operative
touching/scratching site.
operative site.
> Instruct Pt and SOs > To prevent growth of
to immediately report MOs on dressings that
when dressings are may cause contamination
soaked. of operative site.
> Demonstrate to Pt. > To emphasize
and SOs the proper way importance of aseptic
of giving wound care techniques in preventing
with emphasis on proper infection/contamination of
handwashing. operative site.
> Inform Pt. and SOs > To prevent growth of
of the importance of MOs especially on
following the prescribed operative site.
drug regimen.
> Advise Pt. to engage in > To promote circulation
early ambulation and at operative site for timely
have his SOs assist him in healing.
such activities.

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