Ncp Surgery

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NURSING CARE PLAN ASSESSMENT SUBJECTIVE “masuol la gehap an akon tiyan.” as verbalized OBJECTIVE    

minimal movement presence of penrose drain presence of colostomy incised wound at RLQ of abdomen



Guarding the abdominal incision with right hand.



Pain at periumbilical area radiating to RLQ region.



facial grimace noted

NURSING DIAGNOSIS Acute pain related to presence of incision RLQ of abdomen secondary to acute appendicitis

SCIENTIFIC RATIONALE

OBJECTIVES/ PLANNING

NURSING INTERVENTIONS

Tissue injury or infection After a series of  Assess pain, results to immediate vascular nursing interventions noting location, response; transitory the patient will be characteristics, vasoconstriction followed able to: severity (0–10 immediately by vasodilation scale). due to the release of  Verbalize feeling histamine,bradykinin and Investigate and of relief or prostaglandin which in turn reduced sensation report changes in leads to increased capillary from pain. pain as permeability, hyperemia and appropriate. cellular exudation that results  The patient PRS to edema and then pain caused will reduce from by compression of nerve 6 at least 2 out of endings, release of pain 10. >Keep at rest in mediators bradykinin and semi-Fowler’s prostaglandins and eventually loss or impaired function. position.  Reduce guarding behavior Reference: Josie QuiambaoUdan,Mastering Fundamentals of Nursing 3rd edition, p. 156  Follow prescribed pharmacological regimen

>Encourage early ambulation. Provide comfort measures such as repositioning And fixing the bed sheets.





Monitor patient’s vital signs (BP,HR,RR,Temp)



Encourage adequate periods of rest and sleep.



Administer antibiotics

SCIENTIFIC RATIONALE

EVALUATION

Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention. >To lessen the pain. Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.

>Patient will verbalize feeling of relief or reduced sensation of pain.  The patient PRS will reduce from 6 at least 2 out of 10.

>

>Promotes

normalization of organ function (stimulate s peristalsis and passing of flatus, reducing abdominal discomfort) 

To promote comfort and alleviate pain.



Reduce guarding behavior

and analgesics as prescribed such as ketorolac



 



Provide diversional activities



Are usually altered when there is pain as the body is trying to fight and compensate. To maximize energy available for healing and meet comfort needs. As pharmacological management for pain and infection as indicated by the physician.

Watch closely for  Refocuses possible surgical attention, complications. promotes relaxation, and may enhance coping abilities.  Continuing pain and fever may signal an abscess.

NURSING CARE PLAN

Assessment S: >”makatol ak tiyan”

O: >presence of abdominal incision at RLQ region, 4 inches. > presence penrose drain >presence of colostomy >long untrimmed nails >itchiness at the affected area

Diagnosis Impaired skin and tissue integrity related to incised wound at RLQ of the abdomen secondary to post appendectomy

Scientific Rationale >state in which an individual experience damage to integumentary or subcutaneous tissues. Break in the skin wall has greater possibility for sepsis and damage to skin integrity. Appendectomy is a surgical operation done to remove inflamed vernix appendix in order to prevent further damage to neighboring tissues.

Planning >after 8 hours of nursing interventions the pt will be able to: >relieve timely wound healing >significant others will verbalize understanding condition and its causes >demonstrate lifestyle changes to promote healing and prevent recurrence of complications

Intervention >Assess skin/tissue/pressure area and wounds for any signs of infection >. Provide routine incisional care, being careful to keep dressing dry and sterile. Assess and maintain patency of drains.

>assist with encouraged position changes if tolerated

Quimbao, Basic nursing skills; 5th edition, volume 2 >keep the bed linens dry and wrinkle free, use pads under elbows for support and proper positioning. >Instruct patient the importance of proper diet and food intake >Educate the patient on the importance of keeping the skin clean and dry

Scientific Rationale >prevent infection

>Promotes healing. Accumulation of serosanguineous drainage in subcutaneous layers increases tension on suture line, may delay wound healing and serves as a medium for bacteria growth

>Reduces pressure on skin, promoting peripheral circulation and reducing risk of skin breakdown. Skin barrier reduces risk of shearing injury.

>reduces pressure on susceptible areas and risk of abrasions breakdown

>nutrition is the fundamental cellular integrity and tissue repair

>moisture softens the skin and causes a break in the skin

Assessment S: >”di siya nakakaturog kay masuol ura-ura” verbalized by the mother O: >yawning >pain at RLQ scale of 7 (1-10) >fatigue scale rate of 6(1-10)

Diagnosis Fatigue related to sleep deprivation secondary to pain in the right femoral area radiating to the tibia and ulna region.

Scientific Rationale > prostaglandin due to inflammatory reaction as a result from the wound, or micro organism may result to transmission of pain thereby affects mobility, mood, rest and concentration. Reference: Josie QuiambaoUdan,Mastering Fundamentals of Nursing 3rd edition,

Planning >after 8 hours of nursing interventions the pt will be able to: >verbalize an increase of energy >fatigue scale from 6 will improve to 3

Intervention >manipulated environment such as cleaning the surroundings and minimizing noise. >encourage patient for adequate rest periods to obtain rest and relieve fatigue >have patient in any comfortable position as tolerated

Scientific Rationale >to promote comfort

>adequate rest period could prevent fatigue and discomfort

> Client’s position may aggravate pain felt. Positioning properly may promote comfort and also ensure good circulation.

> keep the bed linens dry and wrinkle free to prevent discomforts >instructed to: -consume foods that are rich in protein, vitamins and calcium which can be a source of energy

>nutrition is the fundamental cellular integrity

-refrain from caffeine, alcohol and other stimulating substances specially during evening -perform diversional activities such as listening to music to diver attentions.

and tissue repair

>caffeine has substances that i known to disrupt sleeping patterns

>Encourage deep breathing exercises

> Diversional activities will help the client focus o other things rather than the pain felt

> To facilitate expansion of abdomen and to decrease pain

NURSING CARE PLAN

ASSESSMENT SUBJECTIVE >”inuuhaw ako” OBJECTIVE: >post appendectomy >400cc of urine output per day >dry lips >poor skin turgor >cool clammy skin

NURSING DIAGNOSIS >Fluid volume deficit related to

decrease absorption of fluid secondary to bowel perforation

OBJECTIVES/ PLANNING

SCIENTIFIC RATIONALE Intestines functions not only as a passage of chime but also for digestion, intestine absorbs water, vitamin B and electrolytes. Perforations and infection of bowel may disrupts its normal function causing a decrease in absorption and fluid imbalance.

Source: Stump, Nutritional foundations and clinical applications: a nursing approach,

After a series of nursing interventions the patient will be able to: >

Demonstrate adequate fluid balance, as evidenced by normal skin turgor, moist mucous membranes, and individually appropriate urinary output.

NURSING INTERVENTIONS

SCIENTIFIC RATIONALE

> Measure and

>Accurate

record I&O (including tubes and drains). Calculate urine specific gravity as appropriate.

documentation helps identify fluid losses or replacement needs and influences choice of interventions. >Indicators of adequacy of peripheral circulation and cellular hydration.

>Inspect mucous membranes; assess skin turgor and capillary refill. > Provide voiding assistance measures as needed: privacy, sitting position, running water in sink, pouring warm water over perineum. > Monitor skin temperature, palpate peripheral pulses.

> Monitor laboratory studies: Hb/ Hct, electrolytes. Compare

>Promotes relaxation of perineal muscles and may facilitate voiding efforts.

> Cool or clammy skin, weak pulses indicate decreased peripheral circulation and need for additional fluid replacement. > Indicators of hydration and/or circulating volume. Preoperative anemia and/or low

EVALUATIO

>Patient will hav adequate fluid balance.

Patient w demonstra adequate fluid balan as evidenc by normal skin turgor moist mucous membrane and individuall appropriat urinary output. >

preoperative and postoperative blood studies.

> Give frequent mouth care with special attention to protection of the lips. >Administer IV

fluids and electrolytes.

Hct combined with unreplaced fluid losses intraoperatively will further potentiate deficit. > Dehydration results in drying and painful cracking of the lips and mouth. >The peritoneum reacts to irritation and infecti on by producing large amounts of intestinal fluid, possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances.

NURSING CARE PLAN Assessment S: O: >wt loss noted >wt less than 19kg

Diagnosis Risk for Imbalanced Nutrition: Less Than Body Requirements r/t inability to absorb nutrients secondary post revision of colostomy

Scientific Rationale > colostomy is a surgical procedure in which an opening (stoma) is formed by drawing the healthy end of the large intestine or colon through an incision in the anterior abdominal wall and suturing it into place, depending on the site, less absorption of nutrients such as vitamin B, water and electrolytes due to the presence of colostomy given by its location.

Planning >after 8 hours of nursing interventions the pt will be able to:

Intervention > Auscultate bowel sounds, noting absent or hyperactive sounds.

>increase weight from <19kg to 22kg

> Measure abdominal girth.

Source: Stump,Nutritional foundations and clinical applications: a nursing approach, >Weigh regularly.

> Monitor BUN, protein, prealbumin and albumin, glucose, nitrogen balance as indicated. >Instruct to eat foods that

Scientific Rationale > Although bowel sounds are frequently absent, inflammation and irritation of the intestine may be accompanied by intestinal hyperactivit diminished water absorption, and diarrhea. > Provides quantitative evidence of changes in gastri or intestinal distension and/or accumulation of ascites. > Initial losses or gains reflect changes in hydration, but sustained losses suggest nutrition deficit. > Reflects organ function and nutritional status and needs. >Intake of Vitami C may facilitate i wound healing

are rich in vitamin C. > Support family members to bring the patient's favorite food from home.

> Large portions of food offered during the day when a high appetite.

and nutrition. > Patients feel

comfortable with food brought from home an can improve the appetite of the patien

> By administering a large portion can maintain adequacy of nutrition intake

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