ASSESSMENT S> medyo malaki yung hiwa na ginawa sa singit ko,nasa 2 inches din kaya baka matagalan pang

maghilom ito as verbalized by the client a day after the surgery.

PATHOPHYSIOLOGY OBJECTIVES Surgical Intervention( herniorraphy). Incision on the Left Lower Quadrant to remove the disease tissue(Surgical dressing on the left lower quadrant of his groin). Surgery involves cutting of skin surface and skin layers. Injury on the skin/tissue is inflicted

NURSING INTERVENTION STO>After 1 Dx: hour of >Assessed skin. effective Noted color, nursing turgor and intervention sensation. the patient Described and will be able to measured demonstrate wounds and proper way of observed wound care changes. and proper dressing. >Keep the area clean and dry.

RATIONALE

EVALUATION STO> Goal fully met. After 1 hour of effective nursing intervention the patient was able to: Demonstrate the proper way of wound care and proper dressing.

>Establishes comparative baseline providing opportunity for timely intervention.

O> -dry wound -itchiness -presence of purulent discharge -redness on the skin surrounding the incision site.

Because of injury vasodilatation is present. Because of vasodilatation there is redness on the surrounding tissue on the injury site.

LTO>After 2 days of effective nursing intervention the patient will be able to show improvement in wound healing as evidenced by:

>Periodically re measure and observe for complications. Tx: >Administer prophylactic antibiotic as indicated. (Sulbactam ampicillin) 1.5 gm IV every 8 hours. >Provide appropriate barrier dressings, wound coverings and skin-protective agents for open wounds. >Assist client to learn stress reduction and alternate therapy.

>To assist bodys natural process of repair. >To monitor progress of wound healing.

>To inhibit synthesis of bacterial cell wall causing cell death.

Nsg. Dx: Impaired skin integrity r/t herniorrhaphy.

- absence of redness -absence of purulent discharge -absence of itchiness.

>To protect the wound or surrounding tissues.

LTO> Goal partially met. After 2days of effective nursing intervention the patient was able to show improvement in wound healing as evidenced by: -absence of redness. -absence of purulent discharge. -absence of itchiness.

>To help them control feelings of helplessness and deal with

the situation. Edx:

>Encouraged early ambulation or immobilization.

>Promotes circulation and reduces risks associated with immobility. >Demonstrated >Providing to the family the family members on with how to make a alternative guava solutions decoction to assists them apply to the in optimal wound as healing with alternative less disinfectant. expensive resources. >Emphasized >Improved importance of nutrition and adequate hydration nutrition and will improve increased in skin vitamin c & condition. protein intake.