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Subjective cues:
"First time kong
maoperahan kaya hindi ko
alam ano ba dapat gawin
dito sa bahah" as
verbalized
Objective cues: N/A
Nursing diagnosis:
Knowledge deficit related
to unfamiliarity with
informational resources
Objective of care
> Within 8 hours of
nursing intervention, the
Pt. will
a) verbalize
understanding of the
disease process and
potential complications
b) verbalize
understanding about
proper way of hand
washing and wound
dressing
c) verbalize
understanding about
activity restrictions and
diet modification
Nursing Interventions
Rationale
Implementation
-identify symptoms
requiring medical
evaluation ( increasing
pain, erythematic or edema
on the wound and etc)
-prompt intervention
reduces the risk of serious
complications
-understanding promotes
cooperation with
therapeutic regimen,
enhancing healing and
recovery process
Evaluation
Patient verbalized
understanding about the
health teaching done to the
patient which includes
teaching about the disease
process and potential
complications, proper way
of hand washing and
wound dressing, activity
restrictions and diet
modification
Nursing Assessment
Objective cues
:> v/s taken as follows:
T= 37.0 C
PR= 81 bpm
RR= 23 breaths/min
BP= 140/90 mmHg
> S/P appendectomy
> with dry and intact
dressing on RLQ of
abdomen
Nursing diagnosis:
Risk for infection r/t
tissue trauma
Objective of care
Nursing Interventions
Rationale
Implementation
-instructed to avoid
scratching and touching the
operative site
- To emphasize importance
of aseptic techniques in
preventing
infection/contamination of
operative site.
Evaluation
-The Pt. and SOs verbalized
ways in preventing
infection/ contamination,
specifically proper hand
washing, and proper wound
care.
- To prevent growth of
MOs especially on
operative site.
-To promote circulation at
operative site for timely
healing
Nursing Assessment
Objective of care
Nursing Interventions
Rationale
Subjective cues:
Masakit dito sa baba,
while pointing at RLQ of
abdomen.
> rated pain as 6 on a
scale of 10, where 1 as the
lowest and 10 as the
highest.
> reported that pain
occurs every time Pt.
moves or is moved
b.) engagement in
diversional activities such
as socialization, watching
TV game shows, and
listening to mellow music
-Advised pt to engage in
diversional activities such as
listening to music and reading
books
Objective cues:
> S/P appendectomy
> with surgical incision
on RLQ of abdomen
> facial grimacing upon
movement
> guarding behavior over
surgical site
Nursing diagnostics: Acute
pain r/t skin/tissue trauma
Implementation
Evaluation
> The Pt. manifested ability
to cope with incompletely
relieved pain as evidenced
by:
a.) verbalization of decrease
in pain from 6/10 to 2/10
b.) engagement in
diversional activities such
as socialization, watching
TV game shows, and
listening to mellow music