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 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 flawless injury dressingc. ) investment in latent ROM exercises| >Assess usable site for redness, expanding, free stitches, or doused dressing>Monitor Vital Signs>Assist in inactive movements(while 8hrs. lat on bed, for example, bed turning and latent ROM e xercise and dynamic exercise from there on 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 sentiments particularly torment, distress just as changes noted on usable 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 abstain from contacting/scratching employable 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 gauge data>to elevate dissemination to the careful site for opportune healing>to decrease pressure on the usable site>to permit constant observing and appraisal of pt. o ndition>to elevate dissemination to the careful site for auspicious healing>to elevate course to the careful site for opportune healing>for prompt substitution to forestall skin breakdown and sullying of employable site>to keep away from amassing of dampness at the usable sitewhich may prompt skin breakdown>to forestall microbes harbor in usable site|Within 8 hours of nursing mediation the pt be capable show the following:a. ) flawless suturesb. ) dry and unblemished injury dressingc. ) support in uninvolved ROM exercises>Evaluation was not completed because of time requirements. 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 bp mT: 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 passage to pathogens through:>unnecessary presentation of careful site>inadequate aseptic strategies particularly in twisted dressing>contract with pt’s, SO’s and guests hands or other partsvMay result to infection| Within 8 hours of nursing intercession the pt will be capable verbalize routes in forestalling contamination/defilement explicitly legitimate hand washing, and appropriate injury care as confirm by:>maintain stable v/s>good skin integrity>absence of expanding redness and agony on employable site | >Monitor v/s and record>assess usable site for indications of infection>change cloths as necessary>Provide customary dressing care>Instruct pt a nd SO’s to forgo contacting/scratching usable site>Encourage pt to verbalized any progressions noted on usable site, for example, redness, expanding and unordinary/putrid 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 pattern information to correlation and distinguish requirement for additional management>to forestall development of microorganisms on materials and beds> to forestall superfluous introduction and sullying of usable sitewhich may postpone wound healing>for prompt substitution to forestall skin breakdown and tainting of usable site>to permit nonstop observing and appraisal of pt. condition>to elevate dissemination to the careful site for auspicious healing>serve as prophylactic treatment and forestall microscopic organisms to harbor on employable site|Within 8 hours of nursing intercession the pt will be capable verbalize routes in reventing disease/sullying explicitly appropriate hand washing, and legitimate injury care as prove 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 torment happens everytime when pt moves or movedO&am p;gt; v/s taken as 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 pulverization of skin layersvActivation of nociceptors in dermis and tissuesvReceptors send motivations 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 entirely eased torment as prove bya. ) verbalization of decline torment structure 5/10 to 2/10b. commitment in diversional exercises, for example, socialization, sitting in front of the TV, and listening smooth music| >Monitor V/S and record>Assess torment qualities including area, force, and frequency >Assess careful site for expanding, redness or free sutures>Promote sufficient rest periods by briefly restricting activity>Encourage pt to verbalize torment perception>Provide pt with diversional exercises, for example, socialization, staring at 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 show exacerbating condition>Swelling, redness , and free stitches may add to the torment felt by pt. nd are demonstrative of further management>to decrease torment felt disturbed by movements>to permit further appraisal of agony qualities and assessment of treatment/intervention>to assist pt with occupying his regard for different issues than torment felt>to permit pt proceed redirect his attention>to calmed or diminish torment by repressing prostaglandin synthesis| Within 6-8 hours of nursing mediation, the pt will have the option to show capacity to adapt to deficiently assuaged torment as confirm bya. ) verbalization of diminishing agony structure 5/10 to 0/10b. ) commitment in diversional exercises, for example, socialization, staring at the TV, and listening smooth music>verbal report that agony is totally releived>absence of facial endless supply of exercises, for example, evolving position, sitting ,standing and walking> nonattendance 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 entry point at right lower stomach area>with dry unblemished 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 pulverization 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 uninvolved ROM exercises| >Assess usable site for redness, expanding, free stitches, or drenched dressing>Monitor Vital Signs>Assist in inactive movements(while 8hrs. lat on bed, for example, bed turnin g and latent ROM exercise and dynamic exercise from there on 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 sentiments particularly torment, uneasiness just as changes noted on usable 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 cease from contacting/scratching usable site>Provide customary dressing care>Administer Chlorampenicol Sodium(antibiotic) as ordered| >to check skin honesty, screen progress of mending and recognize requirement for further> Serve as pattern data>to advance circ