Nursing Diagnosis

Topics: Nursing care plan, Nursing, Skin Pages: 4 (1278 words) Published: November 14, 2012
Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| S> “ 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 appendix↓Acute Appendicitis↓Appendectomy↓Dissection if right lower abdominal tissues↓Disruption of skin surface and destruction of skin layers↓Impaired 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. flat on bed) such as bed turning and passive ROM exercise and active exercise thereafter 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. condition>to promote circulation to the surgical site for timely healing>to promote circulation to the surgical site...
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