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ASSESSMENT PATHOPHYSIOLOGY OBJECTIVES NURSING

INTERVENTION

RATIONALE EVALUATION

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.

O>

-dry wound

-itchiness-presence of

purulent

discharge

-redness on

the skin

surrounding

the incision

site.

Nsg. Dx:

Impaired skin

integrity r/t

herniorrhaphy.

Surgical

Intervention(herniorraphy).

Incision on the LeftLower Quadrant to

remove the diseasetissue(Surgical

dressing on the leftlower quadrant of

his groin).

Surgery involvescutting of skin

surface and skin

layers.

Injury on theskin/tissue is

inflicted

Because of injuryvasodilatation is

present.

Because ofvasodilatation there

is redness on thesurrounding tissueon the injury site.

STO>After 1

hour of

effective

nursing

intervention

the patient

will be able to

demonstrate

proper way of

wound care

and proper

dressing.

LTO>After 2

days of

effective

nursing

intervention

the patient

will be able to

showimprovement

in wound

healing as

evidenced by:

- absence of

redness

-absence of

purulent

discharge

-absence of

itchiness.

Dx:

>Assessed skin.

Noted color,

turgor and

sensation.

Described and

measured

wounds and

observed

changes.

>Keep the area

clean and dry.

>Periodically re

measure and

observe for

complications.

Tx:

>Administer

prophylactic

antibiotic as

indicated.

(Sulbactamampicillin) 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.

>Establishes

comparative

baseline

providing

opportunity

for timely

intervention.

>To assist

bodys

natural

process of

repair.>To monitor

progress of

wound

healing.

>To inhibit

synthesis of

bacterial cell

wall causing

cell death.

>To protect

the wound or

surrounding

tissues.

>To help

them control

feelings of

helplessness

and deal with

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.

LTO> Goal

partially met.

After 2days of

effective

nursing

intervention

the patientwas able to

show

improvement

in wound

healing as

evidenced by:

-absence of

redness.

-absence of

purulent

discharge.

-absence of

itchiness.

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Edx:

>Encouraged

early

ambulation or

immobilization.

>Demonstrated

to the family

members on

how to make a

guava

decoction toapply to the

wound as

alternative

disinfectant.

>Emphasized

importance of

adequate

nutrition and

increased in

vitamin c &protein intake.

the situation.

>Promotes

circulation

and reduces

risks

associated

with

immobility.

>Providing

the family

with

alternative

solutions

assists themin optimal

healing with

less

expensive

resources.

>Improved

nutrition and

hydration

will improve

skin

condition.