CUES/ EVIDENCES

NURSING DIAGNOSIS Risk for infection related to impaired primary defense mechanism secondary to surgical incision

SCIENTIFIC BASIS

OUTCOME CRITERIA

NURSING INTERVENTION 1. Note risk factors for occurrence of infection such as environmental exposure and skin integrity.

RATIONALE

EVALUATION

Subjective: no verbal cues Objective: - received patient, lying in bed, sleeping with IVF of D5LR i L infusing well on left arm regulated at 30 gtts/min with the following vital signs: T 36.4 C PR 88 bpm RR 20 cpm BP 140/100 mmHg with transverse incision at lower epigastrium at approximately 13 cm in length dry and intact dressing noted. the color of the surrounding area of the

Infection

After 8 hours of nursing intervention the patient will be free from any signs of infection as evidenced by: - incision site is dry, clean and intact

2. Observe for localized signs of -no fever as evidenced infection at incision by Temp. 37.0-37.5 C. site. - The patient and her S.O will display positive attitudes to prevent infection such as handwashing and disinfection prior to touching the wound. 3. Assess and document skin conditions noting inflammation, secretions and drainage. 4. Note signs and symptoms like fever, chills and excessive sweating. 5. Maintain sterile technique in performing wound dressing. Use gloves upon caring for open lesions. 6. Stress proper handwashing techniques by all caregivers between therapies.

- This will determine the probable contributing factors that could cause infection on the incision site and these will serve as a guide for preventive measures. - For early identification of onset of infection for prompt intervention - Informs the nurse for the occurrence of infection and the appropriate interventions to manage the infected site. -Identifies for the proper treatment.

-Reduces risk for acquiring infection on site.

-Lessens possibility of

incision is pink Laboratory result: WBC: 19.28 k/uL

6. Cleanse incision site daily and whenever necessary with povidone-iodine solution or other appropriate solution. 7. Change dressings that are dry and clean and ensure it is properly done.

contracting nosocomial infections towards the client. Ensures prevention of infection and promotes healing.

8. Review individual nutritional needs.

Clean wound dressing protects the incision site or wound from exposure to bacteria. Encourage intake of protein rich foods to promote healing and repair of cells and high-caloric diet for energy.

9. Instruct client or significant others to protect the integrity of the skin, care for lesions and prevention Promotes cooperation of spread of infection and increases (WAYS). effectiveness in 10. Monitor laboratory preventing infection. tests like WBC count.

11. Administer antibiotics as indicated. Health Teaching to prevent infection Such as Handwashing.

For early and/ or accurate determination for possible occurrence of infection

Increasing intake of foods rich in Vitamin ETC. ETC.

This may be used to treat infections in cases that it has persisted.

CUES Subjective: Di man ko kalihoklihok dai oi. Kapoy jud akong lawas.as verbalized by the client Objective: -patient is not able to stand or sit by his self -stressful appearance -BP is elevated with the range of 140/90150/90 mmHg -he ask for some time to rest

NURSING DIAGNOSIS Activity intolerance related to generalized weakness/ fatigue.

SCIENTIFIC BASIS Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in older patients with a history of cardiopulmonary related problems. Since there is insufficient supply of blood to the body, generalized weakness is noted which can alter the ADLs of the patient.

GOALS AND OUTCOME CRITERIA After 8 hours of nursing interventions the patient will be able to reduce the effects of inactivity, promote optimal physical activity. Specifically the patient will be able to: maintain activity level within capabilities as evidenced by the absence of weakness and fatigue recognize and appreciate the importance of the interventions

NURSING INTERVENTIONS Independent: 1.Assess the patients response to activity, marked increase BP during or after activity; chest pain or dyspnea; excessive fatigue and weakness; diaphoresis; dizziness or syncope. 2.Monitor blood pressure. Measure in both arms and thigh three times, three to five minutes apart while patient is at rest then sitting, the standing for initial evaluation. 3.Provide calm, restful surroundings; minimize environmental activity or noise. Limit the number of visitors and length of stay.

RATIONALE

EVALUATION Goal partially met.

1. The stated parameters are helpful in assessing physiological responses to stress of activity and, if present, are indicators of over exertion. 2. Comparison of pressures provides a more complete picture of vascular involvement or scope of problem.

After 8 hours of nursing interventions patient was able to regain her strength and reduce the effects of inactivity. Specifically, the patient was able to: maintain activity level within capabilities as evidenced by the absence of weakness and fatigue recognize and appreciate the importance of the interventions

3. Helps reduce sympathetic stimulation; promotes relaxation

4.Schedule periods of uninterrupted rest; assist patient with self care activities as needed 5.Instruct patient in relaxation techniques, guided imagery, distractions. Collaborative: 1.Refer to physical therapist.

4. Reduces physical stress and tension that affect blood pressure and the course of hypertension. 5. Can reduce stressful stimuli; produce calming effect, thereby reducing blood pressure.

1.To assess the need for the family or significant others to bring in and an ambulation aid from home

CUES PROBLEM PRIORITY # 1 Subjective: Maglabad akong ulo, ari dapit sa tangkogo unya mura kog malipong. Objective : reports of throbbing pain located in suboccipital region which occurs during waking

NURSING DIAGNOSIS Acute headache related to increased cerebral vascular pressure

SCIENTIFIC BASIS Because of poor tissue perfusion, the heart tries to compensate thus pumping double to meet the demands of the body. Since there is compensatory mechanism, there is increase in blood pressure which leads to acute headache.

GOALS AND OUTCOME CRITERIA After 8 hours of nursing interventions, the patient will be able to report pain is relieved or controlled.

NURSING INTERVENTIONS

RATIONALE

Independent: 1. Determine 1. Facilitates specifics of diagnosis of pain, e.g., problem and location, initiation of characteristics, appropriate intensity (0therapy. 10scale), Helpful in Specifically, the onset/duration. evaluating patient will be able Note nonverbal effectiveness to: cues. of therapy. 2. Encourage/ 2. Minimizes maintain bed stimulation/ verbalize rest during promotes methods that acute phase. relaxation. provide relief 3. Provide/ display recommend 3. Measures relaxed face nonpharmacolo that reduce feel rested gical measures cerebral demonstrate

hours and disappears spontaneou sly reluctance to move head, avoidance of bright lights and noise, wrinkled brow, clenched fists reports of stiffness of neck, dizziness, blurred vision, nausea and vomiting

use of relaxation skills and divertional activities

vascular pressure and that slow/block sympathetic response are effective in relieving 4. Eliminate/ headache minimize and vasoconstrictin associated g activities that complications may aggravate . headache,e.g., 4. Activities that straining at increase stool, vasoconstrict prolonged ion coughing, accentuate bending over. the headache 5. Assist patient in the with presence of ambulation as increased needed. cerebral vascular pressure. 5. Dizziness and Dependent: blurred vision frequently 1. Administer are

for relief of headache, e.g., quiet, dimly lit room and diversional activities.

medications as indicated: Analgesics

CUES/ EVIDENCES Subjective: No verbal cues Objective: - received patient, lying in bed, conscious with IVF of D5LR i L infusing well on left arm regulated at 30 gtts/min with the following vital signs:

NURSING DIAGNOSIS Risk for injury related weak muscle strength secondary to post exposure to spinal anesthesia

SCIENTIFIC BASIS Injury

OUTCOME CRITERIA After 8 hours of nursing intervention, the patient will be able to verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations Specifically the patient will be able

NURSING INTERVENTION 1. Assess the muscle strength of the patient 2. Assess the degree of dependence of the patient. 3. Assess for any signs of lightheadednes s and feeling of faintness 4. Encourage

associated with vascular headache. Dependent: 1. Reduce/ control pain and decrease stimulatio n of the sympathet ic nervous system RATIONALE Certain age groups are at higher risks. One's level in cognitive ability greatly affects decisions and abilities of patient. Certain abilities and styles can influence carelessness and increased

T 36.4 C PR 88 bpm RR 20 cpm BP 140/100 mmHg -edema noted on upper and lower extremities -muscle strength score of 3/5 -dizziness and lightheadednes s on ambulation -needs assistance on task and ambulation

to achieved and or increase the distance of ambulation from the bed to the nurse station

patient to do isometric exercise . 5. Assist the client in doing active ROM 6. Institute safety precaution such as Dangling the feet before ambulation 7. Encourage Deep breathing and coughing exercises 8. Encourage and assist the client in doing and increasing the distance of ambulation. 9. Instructed the S.O to assist in ambulation and to provide rest whenever lightheadednes s occurs.

risk-taking without consideration of consequences. Apathy may enhance disregard for own or other's safety. Patient may feel lightheadedness if one abruptly stands and walk after lying in bed. Prevent possible respiratory complications. Increasing the distance of ambulation further aids in patient's healing by promoting increased circulation and providing positive attitude towards cure.

Cues Subjective: Isaka sa ko bi, alsaha ko, as verbalized by the patient addressing her need of assistance to her husband.

Nursing Diagnosis Impaired physical mobility related to presence of surgical incision secondary to

Scientific Basis Many postsurgical patients are unable to assume a comfortable position because of limitation in independent

Goal and Outcome Criteria After 8 hours of appropriate nursing intervention the patient will be able to display increased muscle strength. Specifically the

Nursing Intervention INDEPENDENT: 1. Assess activity limitation, noting presence or degree of restriction 2. Monitor vital

Rationale

Evaluation Goal met. After 8 hours of appropriate nursing intervention, the patient displayed increase strength and normal range

1. Influences choice of intervention.

2. Change in vital signs may

Objective: -weakness noted -needs full assistance and ambulation -poor muscle strength (grade 4)

purposeful physical movement of the body or of one or more extremities secondary incisional pain, activity restrictions, immobilization devices, or an array of tubes and monitoring lines.

patient will be able to: -appreciate the importance of optimal mobility or ambulation - perform normal range of motion - gain knowledge to choose the right kinds of foods in order to gain muscle strength

signs every four hours.

indicate discomfort.

3. Keep skin clean and dry. 4. Keep linens dry and wrinkle free.

3. Prevent skin irritation. 4. To promote comfort and to prevent irritation.

of motion and appreciated the importance of optimal mobility or ambulation as evidenced by patient able to sit on bed and dangle legs over the edge.

5. Taught deep breathing exercise and encourage frequent change of position when on bed rest.

(Ascani, Mary Ann.et al.Mastering Medical-Surgical

6. Instruct patient and

5. Relieves muscle and emotional tension; decreases discomfort, maintains muscle strength and joint mobility, enhances circulation and prevent skin breakdown.

Nursing: Disorders and Treatments,Nur sing Tips and Guidelines,Patie nt Teaching and Outcome)

assist with active or passive ROM exercises.

7.Encourage ambulation to the level of tolerance of the patient.

6. Maintains joint flexibility, prevents contractures, and aids in reducing muscle tension. 7. To reduce postoperative abdominal distention by increasing gastrointestinal tract and abdominal wall tone and stimulating peristalsis. 8. Adequate intake of protein, Vit.C rich foods to strengthen muscle and boost immune system.

8. Encourage adequate nutritional intake.

(Doenges, Marilynn E. et al.Nurses Pocket Guide:Diagnosis , Prioritized interventions, and Rationales.10th edition.p.509)

(Doenges, Marilynn E. et al.Nurses Pocket Guide:Diagnosis , Prioritized interventions, and Rationales.10th edition.p.509)

Cues Subjective: Ang sakit kay mag-ulyapulyap niya mada raman. Para nako 4/10 ra ang sakit. as verbalized by

Nursing Diagnosis Acute Pain related to surgical incision site secondary to

Scientific Basis Pain is a highly subjective state in which a variety of unpleasant sensations and wild range of distressing

Goal and Outcome Criteria Within 8 hours of nursing intervention the patient will to verbalize a reduction of pain.

Nursing Intervention INDEPENDENT: 1. Assess the location and severity of pain through pain scale of 1-10.

Rationale

Evaluation Goal met. Within 8 hours of nursing interventions the patient verbalized a decrease of pain, from

1. Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal

the patient. Objective: -guarding behavior noted on the incision site -grimaced face noted

factors may be experienced by the sufferer. Pain may be acute, a symptom of injury or illness such as surgical incision. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because is unique to individual; pain should be accepted as described by the sufferer. (Gulanick , Meg.et

Specifically, the patient will be able to: - report that pain is relieved - verbalize methods that provide relief of pain -demonstrate use of relaxation skills and diversional activities as indicated for individual situation - follow prescribed pharmacological regimen

2. Monitor the vital signs.

developing complications. 2. Change in vital signs may indicate acute pain and discomfort. 3. Relieves muscle and emotional tension, enhances sense of control and may improve coping abilities. 4. Reduction of anxiety/fear can promote relaxation/comf ort.

4/10 to 1/10.

3. Encourage deep breathing exercise.

4. Encourage verbalization of feelings of pain.

5. Provide comfort measures like change in position. 6. Encourage diversional

5. May relieve pain and enhance

al.Nursing Care Plans)

activities like listening to music. DEPENDENT: 1. Administer analgesic like Revalan 500 mg 1 tab every 6 hours P.O. RTC as prescribed by the physician.

circulation. 6. Refocuses attention, thereby reducing pain and discomfort.

1. Relieves pain, enhances comfort and promotes rest.

(Doenges, Marilynn E. et al.Nurses Pocket Guide:Diagnosis , Prioritized interventions, and Rationales.10th edition.p.388)

(Doenges, Marilynn E. et al.Nurses Pocket Guide:Diagnosis , Prioritized interventions, and Rationales.10th

edition.p.388)