Nursing Diagnosis

Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| S> â€Å" Hindi dad masyado magaling ang sugat ko† as verbalized by the patientO> S/P Appendectomy>with careful entry point at right lower stomach area>with dry flawless dressing on the careful site| Impaired Skin Integrity identified with skin/tissue trauma| Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower stomach tissuesvDisruption of skin surface and annihilation of skin layersvImpaired skin/tissue integrity|Within 8 hours of nursing mediation the pt will have the option to show the following:a. ) flawless suturesb. ) dry and unblemished injury dressingc. ) cooperation in detached ROM exercises| >Assess usable site for redness, growing, free stitches, or doused dressing>Monitor Vital Signs>Assist in inactive movements(while 8hrs. lat on bed, for example, bed turning and aloof ROM exercise and dynamic exercise from there on developments, for example, bed position, sitting, standing, walking> Support cut as in bracing when hacking and during movement>Encourage pt to verbalized his for any untoward emotions particularly torment, uneasiness just as changes noted on employable site>Encourage pt to connect early ambulation and have SO’s help him in such activities>Instruct pt and SO’s to promptly report when dressing are soaked>Instruct pt and SO’s to avoid contacting/scratching usable site>Provide ordinary dressing care>Administer Chlorampenicol Sodium(antibiotic) as ordered| >to check skin honesty, screen progress of recuperating and distinguish requirement for further> Serve as standard data>to elevate dissemination to the careful site for convenient healing>to diminish pressure on the usable site>to permit ceaseless observing and evaluation of pt. ondition>to elevate dissemination to the careful site for convenient healing>to elevate flow to the careful site for auspicious healing>for quick substitution to forestall skin breakdown and defilement of usable site>to evade collection of dampness at the usable sitewhich may prompt skin breakdown>to forestall microscopic organisms harbor in usable site|Within 8 hours of nursing mediation the pt be capable show the following:a. ) unblemished suturesb. ) dry and flawless injury dressingc. ) support in uninvolved ROM exercises>Evaluation was not done because of time limitations. Pt was embraced to succeeding individuals from the wellbeing group for additional administration 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 flawless dressing on the careful site| Risk for disease identified with tissue trauma| Inflammation of the appendixvAcute AppendicitisvAppendectomyvTissue injury on RLQ abdomenMay give gateway of section to pathogens through:>unnecessary introduction of careful site>inadequate aseptic methods particularly in twisted dressing>contract with pt’s, SO’s and guests hands or other partsvMay result to infection| Within 8 hours of nursing mediation the pt will be capable verbalize routes in forestalling contamination/tainting explicitly appropriate hand washing, and legitimate injury care as confirm by:>maintain stable v/s>good skin integrity>absence of expanding redness and agony on usable site | >Monitor v/s and record>assess usable site for indications of infection>change materials as necessary>Provide customary dressing care>Instruct pt and SOâ€⠄¢s to shun contacting/scratching employable site>Encourage pt to verbalized any progressions noted on usable site, for example, redness, expanding and abnormal/smelly seepage >Encourage pt to connect early ambulation and have SO’s help him in such activities>Administer Penicillin G Sodium(antibiotic) as ordered| >Elevation in rates may flag infection>to give gauge information to examination and distinguish requirement for additional management>to forestall development of microorganisms on cloths and beds> to forestall pointless presentation and pollution of usable sitewhich may postpone wound healing>for prompt substitution to forestall skin breakdown and sullying of usable site>to permit nonstop checking and appraisal of pt. condition>to elevate dissemination to the careful site for opportune healing>serve as prophylactic treatment and forestall microscopic organisms to harbor on employable site|Wi thin 8 hours of nursing intercession the pt will be capable verbalize courses in reventing disease/sullying explicitly appropriate hand washing, and legitimate injury care as confirm by:>maintain stable v/s>good skin integrity>absence of expanding redness and torment on usable site>Evaluation was not done because of time limitations. Pt was supported to succeeding individuals from the wellbeing group for additional administration 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 likewise sa baba†, while pointing at RLQ of midsection. >rated torment as 5 on a size of 10, where 1 as the least and 10 as the highest>characterized torment as pricking>reported that agony happens everytime when pt moves or movedO> v/s taken a s followsT: 37. CRR: 21 cpmPR: 64 bpmBP: 120/70 mmHg> S/PAppendectomy>with dry flawless dressing on the careful site>with guarding conduct over the site>facial grimacing| Acute agony identified with tissue harm second to post appendectomy| Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower stomach tissuesvDisruption of skin surface and obliteration of skin layersvActivation of nociceptors in dermis and tissuesvReceptors send driving forces to CNS for interpretationvPain PerceptionvAcute Pain| Within 6-8 hours of nursing intercession, the pt will have the option to show capacity to adapt to not completely eased torment as confirm bya. ) verbalization of lessening torment structure 5/10 to 2/10b. commitment in diversional exercises, for example, socialization, staring at the TV, and listening smooth music| >Monitor V/S and record>Assess torment qualities including area, force, and frequency>Assess car eful site for growing, redness or free sutures>Promote sufficient rest periods by briefly constraining activity>Encourage pt to verbalize torment perception>Provide pt with diversional exercises, for example, socialization, sitting in front of the TV, and listening smooth music>Encourage SO’s to proceed with arrangement of diversional exercises and a calm situation >Administer Toradol (analgesic)as requested | >Elevation in rates propose expanded torment power and frequency>Elevation in power and recurrence may demonstrate compounding condition>Swelling, redness , and free stitches may add to the agony felt by pt. nd are demonstrative of further management>to decrease torment felt bothered by movements>to permit further appraisal of agony attributes and assessment of treatment/intervention>to assist pt with occupying his regard for different issues than torment felt>to permit pt proceed redire ct his attention>to calmed or reduce torment by hindering prostaglandin synthesis| Within 6-8 hours of nursing intercession, the pt will have the option to show capacity to adapt to deficiently mitigated torment as prove bya. ) verbalization of decline torment structure 5/10 to 0/10b. ) commitment in diversional exercises, for example, socialization, staring at the TV, and listening smooth music>verbal report that torment is totally releived>absence of facial endless supply of exercises, for example, evolving position, sitting ,standing and walking> nonappearance of guarding conduct over careful site>Evaluation was not done because of time imperatives. Pt was supported to succeeding individuals from the wellbeing group for additional administration and evaluation| Nursing Diagnosis Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| S> â€Å" Hindi dad masyado magaling ang sugat ko† as verbalized by the patientO> S/P Appendectomy>with careful cut at right lower stomach area>with dry flawless dressing on the careful site| Impaired Skin Integrity identified with skin/tissue trauma| Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower stomach tissuesvDisruption of skin surface and devastation of skin layersvImpaired skin/tissue integrity|Within 8 hours of nursing mediation the pt will have the option to show the following:a. ) unblemished suturesb. ) dry and flawless injury dressingc. ) support in aloof ROM exercises| >Assess employable site for redness, growing, free stitches, or drenched dressing>Monitor Vital Signs>Assist in uninvolved movements(while 8hrs. lat on bed, for example, bed turning and aloof RO M exercise and dynamic exercise from that point developments, for example, bed position, sitting, standing, walking> Support entry point as in bracing when hacking and during movement>Encourage pt to verbalized his for any untoward emotions particularly torment, inconvenience just as changes noted on employable site>Encourage pt to connect early ambulation and have SO’s help him in such activities>Instruct pt and SO’s to quickly report when dressing are soaked>Instruct pt and SO’s to avoid contacting/scratching usable site>Provide customary dressing care>Administer Chlorampenicol Sodium(antibiotic) as ordered| >to check skin honesty, screen progress of recuperating and distinguish requirement for further> Serve as standard data>to advance circ