ASSESSMENT O: -Dressing on surgical site -Pale

DIAGNOSIS Risk for infection related to incision/suture in the right lower abdominal area.

PLANNING Short Term Goal: At the end of the shift, the client will identify interventions to prevent or reduce risk of infection. Long Term Goal: Within hospitalization, the client will achieve timely wound healing; be free of purulent drainage.

INTERVENTION
1. Note risk factors for occurrence of infection (e.g., skin/tissue wounds)

RATIONALE

EXPECTED OUTCOME

2. Stress proper hand hygiene by all caregivers between therapies and clients. 3. Assess and document skin conditions, noting inflammation and drainage. 4. Cleanse incision site per facility control with appropriate solution. 5. Administer or monitor medication regimen. 6. Emphasize necessity of taking antibiotics as directed.

To assess At the end of the shift causative/contributing the client will identify factors. interventions to prevent or reduce risk of A first-line defense infection like initiating against healthcare change of dressing on associated infections. surgical site and verbalizing the importance of daily hand washing. Within hospitalization the client will achieve timely wound healing as marked by absence of secretions in the dressing and verbalizing of the healing wound.

To reduce potential for catheter-related blood-stream infections. To determine effectiveness of therapy/presence of side effects.

ASSESSMENT S: -Pain scale of 7/10 O: -Dressing on surgical site -Pale -Facial grimacing

DIAGNOSIS Acute pain related to presence of surgical incision as manifested by facial grimacing.

PLANNING Short Term Goal: At the end of the shift, the client will report pain is relieved and controlled. Long Term Goal: Within hospitalization, the client will verbalize nonpharmacologic methods that provide relief.

INTERVENTION
1. Note clients

RATIONALE To assess etiology/precipitating contributing factors.

EXPECTED OUTCOME At the end of the shift the client will report pain is relived and controlled by verbalizing that his pain scale from 7/10 becomes 2/10 after taking medication. Within hospitalization the client will verbalize nonpharmacologic methods that provide relief like use of diversional activities such as TV, radio and socialization with others.

age/developmental level and condition affecting ability to report pain parameters. 2. Note location of surgical procedures. 3. Assess for referred pain, as appropriate. 4. Obtain clients assessment of pain to include location, characteristics, quality, intensity, etc. 5. Instruct an use of relaxation techniques (e.g., focused breathing) and diversional activities. 6. Administer analgesics as indicated to maximum dosage, as needed.

Influence the amount of post operative pain experienced. To help determine possibility of underlying condition. To rule out worsening of underlying condition/development of complication.

To distract attention and reduce tention.

To maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal.

ASSESSMENT O: -With surgical incision at right lower abdominal area

DIAGNOSIS Impaired skin integrity related to destruction of skin/tissue layers.

PLANNING Short Term Goal: At the end of the shift, the client will display timely healing of skin lesions/wounds without complication Long Term Goal: After hospitalization, the client will participate in prevention measures and treatment program.

INTERVENTION
1. Determine nutritional

RATIONALE

EXPECTED OUTCOME

To assess At the end of the shift status potential for causative/contributing the client will display delayed healing factors. timely healing of skin exacerbated by lesions/wounds without malnutrition. complication by manifesting intact 2. Evaluate client with To identify risk for sutures and dry wound impaired cognition, injury/safety dressing. need/use of restraints, requirements. long term immobility. After hospitalization, the client will 3. Periodically remeasure To monitor progress participate in wound and observe for of wound healing. prevention measures complications. and treatment program like participating in in 4. Keep area clean/dry, passive range of motion carefully dress wounds, To assess bodys exercises. support incision. natural process of repair. 5. Encourage early Promotes circulation ambulation/mobilization. and reduces risks associated with immobility. 6. Assist the client/SO(s) Enhances in understanding and ff. commitment to plan, medical regimen and optimizing outcomes. daily maintenance.

ASSESSMENT O: -With surgical incision at right lower abdominal area

DIAGNOSIS Activity intolerance related to presence of surgical incision as manifested by limited mobility.

PLANNING Short Term Goal: At the end of the shift, the client will verbalize understanding of potential loss of ability in relation to existing condition. Long Term Goal: After hospitalization, the client will participate in conditioning and rehabilitation program to enhance ability to perform.

INTERVENTION
1. Note presence of

RATIONALE This may have potential for interfering with clients ability to perform at a desired level of activity. Provides baseline for comparison and opportunity to track changes.

EXPECTED OUTCOME At the end of the shift the client will verbalize understanding of potential loss of ability in relation to existing condition like verbalizing
habits and lifestyle that is appropriate to his condition.

medical diagnosis/ regimens.

2. Determine current activity level/physical condition with observation, exercise tolerance testing. 3. Implement physical therapy exercise with client and team members. 4. Instruct client in unfamiliar activities and alternate ways of doing familiar activities. 5. Assist client/SO(s) with planning for changes that may become necessary, such as use of supplemental oxygen.

Coordination of program enhances likelihood of success.

To conserve energy and promote safety.

After hospitalization, the client will participate in conditioning and rehabilitation program to enhance ability to perform like doing ROMEx, and relaxation techniques.

To improve clients ability to participate in desired activities.

ASSESSMENT O: -With surgical incision at right lower abdominal area -weight loss

DIAGNOSIS Imbalanced nutrition: less than body requirements related to nausea and vomiting, loss of appetite and decrease peristalsis as manifested by loss of weight.

PLANNING Short Term Goal: At the end of the shift, the client will demonstrate progressive weight gain toward goal. Long Term Goal: After hospitalization, the client will demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.

INTERVENTION 1. Determine clients ability to chew, swallow and taste food. 2. Discuss eating habits, including food preferences, intolerances/aversions. 3. Assess weight; measure/calculate body fat/muscle wasting, etc. 4. Evaluate total daily food intake, patterns and times of eating. 5. Consult dietician/nutritional team, as indicated. 6. Administer vitamin/mineral supplements as indicated. 7. Assist client/SO(s) to learn how to blenderize food.

RATIONALE All factors that can affect ingestion and/or digestion of nutrients. To appeal to clients like and dislikes.

EXPECTED OUTCOME At the end of the shift the client will demonstrate progressive weight gain toward goal by verbalizing to take in nutrients to meet metabolic needs. After hospitalization, the client will demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight like taking adequate food, increase in appetite and interest in food.

May indicate proteinenergy malnutrition.

May have changes that could be made in clients intake. To implement interdisciplinary team management.

Supervision/home nutrition therapy.