Assessment Subjective: kumikirot-kirot yung bandang inoperahan as verbalized by the patient.

Objective: Observed evidence of pain; facial grimace Verbalized pain at the abdomen with a pain scale of 5/10 Guarding behaviour in the incision site. Positioning to avoid pain

Diagnosis Acute pain related to presence of surgical incision as manifested by facial grimace and report of pain.

Planning Intervention After 4 hours of Independent: nursing intervention, Assess pain, the patient will be noting location, able to verbalize characteristics, relief of pain or at severity (0-10). least pain is reduced Investigate and from pain scale 5/10 report changes in to 3/10 and also the pain as patient will be able to appropriate. appear relaxed.

Rationale Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristics of pain may indicate developing abscess/ peritonitis, requiring prompt medical evaluation and intervention Gravity localizes inflammatory exudates into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.

Evaluation After 4 hours of nursing intervention, the patient was able to verbalize pain is reduced from pain scale 5/10 to 3/10 and also the patient was able to appear relaxed.

Keep at rest in semi-Fowlers position.

 Encourage early ambulation.

Promotes normalization of organ function. Refocuses attention, promotes relaxation, and may enhance coping abilities.

Provide diversional activities.

Collaborative:

Keep NPO/ maintain NG suction initially.

Decreases discomfort of early intestinal peristalsis and gastric irritation/vomitin g. Relief of pain facilitates cooperation with other therapeutic interventions.

Administer analgesics as indicated.

 Place ice bag on the abdomen periodically, during initial 2448 hours as appropriate.

Soothes and relieve pain through desensitization of nerve endings. Note: do not use heat because it may cause tissue congestion/ increase edema formation.

Assessment Subjective: Hindi pa masyado magaling ang sugat ko as verbalized by the patient Objective: S/P Appendectomy with surgical incision at right lower abdominal area with dry intact dressing on the surgical site

Diagnosis Impaired Skin Integrity related to skin/tissue trauma

Planning Within 8 hours of nursing intervention the pt will be able to manifest the following: a.) intact sutures b.) dry and intact wound dressing

Intervention >Assess operative site for redness, swelling, loose sutures, or soaked dressing

Rationale >to check skin integrity, monitor progress of healing and identify need for further > Serve as baseline data

Evaluation Within 8 hours of nursing intervention the pt be able manifest the following: a.) intact sutures b.) dry and intact wound dressing >Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation

>Monitor Vital Signs

> Support incision as in splinting when coughing and during movement >Encourage pt to verbalized her for any untoward feelings especially pain, discomfort as well as changes noted on operative site >Encourage pt to engage early ambulation and have SOs assist him in such activities

>to reduce pressure on the operative site >to allow continuous monitoring and assessment of pt. condition

>to promote circulation to the surgical site for timely healing

>Instruct pt and SOs to >to promote immediately report when circulation to the dressing are soaked surgical site for timely healing

>Instruct pt and SOs to refrain from touching/scratching operative site

>for immediate replacement to prevent skin breakdown and contamination of operative site

>Provide regular dressing >to avoid care accumulation of moisture at the operative site which may lead to skin breakdown >Administer >to prevent bacteria Metronidazole(antibiotic) harbor in operative as ordered site

Assessment Subjective: Hindi naman ako nilalagnat, as verbalized by the patient

Diagnosis Risk for infection related to skin trauma

Planning 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

Intervention >Monitor v/s and record

Rationale

Evaluation

>assess operative site for signs of infection

Objective: Vital Signs taken as follows: BP:140/80 mmHg RR:28 cpm PR:93 bpm T: 37.1 C > S/P Appendectomy >with dry intact dressing on the surgical site

>change linens as necessary

>Provide regular dressing care

>Instruct pt and SOs to refrain from touching/scratching operative site

>Elevation in rates Within 8 hours of may signal infection nursing intervention the pt will be able verbalize >to provide ways in preventing baseline data for infection/contamination comparison and specifically proper hand identify need for washing, and proper further wound care as management evidenced by: >maintain stable v/s >to prevent growth >good skin integrity of microorganisms >absence of swelling on linens and beds redness and pain on operative site > to prevent >Evaluation was not unnecessary carried out due to time exposure and constraints. Pt was contamination of endorsed to succeeding operative site members of the health which may delay team for further wound healing management and evaluation >for immediate replacement to prevent skin breakdown and

contamination of operative site >Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage >to allow continuous monitoring and assessment of pt. condition

>Encourage pt to engage early ambulation and have SOs assist him in such activities >Administer Penicillin G Sodium(antibiotic) as ordered

>to promote circulation to the surgical site for timely healing >serve as prophylactic treatment and prevent bacteria to harbor on operative site