Assessment Objective: y Post-Surgical Incision Risk Factors: y Environmental Factor y Decreased tissue perfusion y Decreased wound healing time

y Nutritional Imbalances

Diagnosis Planning Risk for infection After 8 hours of related to postnursing intervention, surgical incision the patient will: Short term: Identify the risk factors that are present Have partial understanding about infection control Long term: Clients full knowledge in identifying the risk factors of the infection Be free from any signs and symptoms related to infection

Intervention Independent: 1.Note risk factors for occurrence of infection in the incision 2. Observed for localized sign of infection at insertion sites of invasive lines, surgical incisions or wounds.

Rationale
To help the patient identify the present risk factors that may add up to the infection To evaluate if the character, presence and condition of the present infection To help the client modify/change/avoid some of the environmental factors present which could reduce the incidence of infection.

Evaluation After 8 hours of nursing intervention, the patient was able to meet the goals with an evidence of the absence of the signs and symptoms related to infection

3. Make health teachings especially in identification of Antibiotics will help environmental risk factors that could add kill and stop the proliferation and up on infection. Dependent: 1. Administer antibiotics as ordered by the physician

growth of the bacteria which could cause infection

Assessment Subjective: y Reports of pain on the incision site.

Nursing Diagnosis Acute pain related to tissue trauma secondary to exploratory laparotomy

Inference Exploratory Laparoscopy

Goal After 30 minutes to 1 hour of nursing interventions, the clients pain will lessen.

Implementation Assess verbal/nonverbal reports of pain, noting location, intensity (0-10 scale), and duration.

Rationale y Useful in evaluating pain, choice of interventions, effectiveness of therapy. y To lessen the pain.

Evaluation Goal met. The clients pain scale decreased from 8/10 to 4/10.

Surgical incision

Objective: y Status: post exploratory laparotomy Irritable Facial grimace Restlessness Pain scale of 8/10 Damage on the tissues/ Tissue trauma Place the patient in a comfortable position.

y y y y

Pain

Encourage deep breathing exercises.

To relax the abdominal muscles.

Encourage patient to use relaxation techniques like watching TV, soft music, progressive relaxation.

y Helps refocus attention and assists patient to manage pain/discomfort more effectively.

Assessment

Nursing Diagnosis Impaired skin integrity related to postsurgical incision

Inference

Goal

Implementation

Rationale

Evaluation

Objective: y Presence of surgical wound

Exploratory Laparoscopy

Surgical incision

Surgery involves cutting /penetration of skin surface and skin layers

After 20-30 minutes of nursing interventions, the patient will be able to demonstrate proper way of wound care.

Keep the area clean and dry.

Moisture harbors bacteria and pathogens. Splinting provides support to the area minimizing discomfort. Frequent assessment can detect early signs and symptoms of infection. To promote wound healing. To increase compliance.

Provide a splinting pillow.

Goal met. The patient was able to demonstrate proper way of wound care.

Inspect the incision site every shift.

Injury/trauma on the skin y Increase protein intake. Impaired skin integrity Inform patient the importance of self-care practices. y

Assessment

Nursing Diagnosis

Inference

Goal

Implementation

Rationale

Evaluation

Subjective: Hirap ako makagalaw dahil sa tahi at sa colostomy bag na nakalagay sakin. As verbalized by the patient.

Objective: Irritated.

Disturbed body Verbalization of image related feelings that reflect to surgery. an altered view of one's body in appearance, structure, or function, Verbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function, behaviors of avoidance, monitoring, or acknowledgment of one's body

After 30 minutes of nursing intervention, the patient will be able to: Demonstrate enhanced body image and selfesteem as evidenced by ability to look at, touch, talk about, and care for actual or perceived altered body part/function.

Independent: -Assess perception of change in structure/function of body part. extent of response is more related to the valve or importance patient places on the part of function than the actual value or importance. stages of grief over loss of a body part or function are normal, and typically involve a period of denial. patients may perceive changes that are not present/real.

After 30 minutes of nursing intervention, the patient was able to: Demonstrate enhanced body image and selfesteem as evidenced by ability to look at, touch, talk about, and care for actual or perceived altered body part/function.

-Acknowledge normally of emotional response to actual or perceived change in body structure/function.

-Help patient identify actual changes