NCP Surgery
NCP Surgery
NCP Surgery
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
>Encourage early
ambulation.
Provide comfort
measures such as
repositioning
And fixing the bed sheets.
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)
Reduce
guarding
behavior
and analgesics as
prescribed such as
ketorolac
Provide
diversional
activities
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.
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
> Clients
position may
aggravate pain felt.
Positioning properly
may promote comfort
and also ensure good
circulation.
>nutrition is the
fundamental
cellular integrity
>caffeine has
substances that i
known to disrupt
sleeping patterns
> Diversional
activities will help
the client focus o
other things
rather than the
pain felt
> To facilitate
expansion of
abdomen and to
decrease pain
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
>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.
EVALUATIO
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.
fluids and
electrolytes.
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
Source: Stump,Nutritional
foundations and clinical
applications: a nursing
approach,
>Weigh regularly.
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
and nutrition.
> Patients feel
> By administering a
large portion can
maintain adequacy of
nutrition intake