NCP

CUES Subjective:> Hindi pa masyado magaling ang sugat ko as verbalized by the patient. NURSING DIAGNOSIS INFERENCE EXPECTED OUTCOME NURSING INTERVENTION INDEPENDENT: >Assess operative site for redness, swelling, loose sutures, or soaked dressing >Monitor Vital Signs RATIONALE >to check skin integrity, monitor progress of healing and identify need for further EVALUATION After 8 hours of nursing intervention the goal has been met as manifested by the following: a.) intact sutures b.) dry and intact wound dressing c.) participation in passive ROM exercises

Objective> With surgical incision: EXLAP right hemicolectomy

Impaired Appendectomy/EXLAP After the 8 hours Skin Integrity of nursing related to Tissue trauma intervention the skin/tissue client will be able trauma as Disruption of cell to manifest the evidenced by the membrane following: surgical incision at right Starts of a.) intact sutures Hemicolectomy area inflammatory process EXLAP. b.) dry andintact IMPAIRED SKIN wounddressing INTEGRITY c.) participation in passive ROM exercises

> Serve as baseline data >to promote circulation to the surgical site for timely healing

>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, turning to sides every 2 hours.

>Instruct to immediately report when dressing are soaked

to prevent the contamination and accumulation of bacteria in the incision site >for immediate replacement to prevent skin

>Instruct to refrain from touching/scratching

NCP
operative site breakdown and contamination of operative site >to avoid accumulation of moisture at the operative site which may lead to skin breakdown >for fast wound healing process.

>Provide regular dressing care

>increased protein and fluid intake. DEPENDENT: >Administer antibiotic therapy as ordered COLLABORATIVE: >wound dressing every shift.

>to prevent bacteria harbor in operative site.

>for continuity of care.

NCP
CUES Subjective:> medyo masakit ang sugat ko as verbalized by the patient. NURSING DIAGNOSIS Acute pain related to inflammation of tissue in the incision site. INFERENCE Appendectomy/EXLAP Tissue trauma Disruption of cell membrane Starts of inflammatory process Release of chemical mediators (prostaglandin) Acute pain in incision site. EXPECTED OUTCOME After 4 hrs. of nursing interventions, the patient will demonstrate use of relaxation skills and other method to promote comfort. NURSING INTERVENTION Independent: Monitor patients vital signs (esp. temperature) Maintain semifowlers position. RATIONALE Notes progress and changes of condition. Reduces abdominal distention, thereby reduces tension. EVALUATION After 4 hrs. of nursing interventions, the patient was demonstrated use of relaxation skills and other method to promote comfort. The goal was met as evidenced by pain scale from 7/10 to 5/10, and no facial mask and guarding behavior of pain.

Objective> Facial mask of pain Guarding behavior Pain scale of 7/10 EXLAP right hemicolectomy

Move patient slowly and deliberately.

Reduces muscle tension or guarding, which may help minimize pain of movement. Promotes relaxation and may enhance patients coping abilities by refocusing attention.

Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. Provide frequent oral care. Remove noxious environmental stimuli.

Reduces nausea and vomiting, which can increase intra-abdominal pressure or pain.

NCP
Dependent: Maintain IV fluids and administer antibiotic ordered by physician. Helps prevent complications and decrease the risk of infection.

Collaborative: Monitor hematologic test & other pertinent lab records. Discuss the patient with other members of the health care team.

Indicates presence of infection.

Ensures continuous interventions.

NCP
CUES Subjective:> medyo masakit ang sugat ko as verbalized by the patient. NURSING DIAGNOSIS Acute pain related to inflammation of tissue in the incision site. INFERENCE Appendectomy/EXLAP Tissue trauma Disruption of cell membrane Starts of inflammatory process Release of chemical mediators (prostaglandin) Acute pain in incision site. EXPECTED OUTCOME After 4 hrs. of nursing interventions, the patient will demonstrate use of relaxation skills and other method to promote comfort. NURSING INTERVENTION Independent: Monitor patients vital signs (esp. temperature) Maintain semifowlers position. RATIONALE Notes progress and changes of condition. Reduces abdominal distention, thereby reduces tension. EVALUATION After 4 hrs. of nursing interventions, the patient was demonstrated use of relaxation skills and other method to promote comfort. The goal was met as evidenced by pain scale from 7/10 to 5/10, and no facial mask and guarding behavior of pain.

Objective> Facial mask of pain Guarding behavior Pain scale of 7/10 EXLAP right hemicolectomy

Move patient slowly and deliberately.

Reduces muscle tension or guarding, which may help minimize pain of movement. Promotes relaxation and may enhance patients coping abilities by refocusing attention.

Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. Provide frequent oral care. Remove noxious environmental stimuli.

Reduces nausea and vomiting, which can increase intra-abdominal pressure or pain.

NCP
Dependent: Maintain IV fluids and administer antibiotic ordered by physician. Helps prevent complications and decrease the risk of infection.

Collaborative: Monitor hematologic test & other pertinent lab records. Discuss the patient with other members of the health care team.

Indicates presence of infection.

Ensures continuous interventions.