ASSESMENT

P>Pyeololithotomy
S> Hindi naman
kumakati yung sugat
ko, masakit lang
talaga siya.
O> Wound is about
15cm in length and
0.8cm in width
>No redness, swelling
and pus on the wound
>With serous discharge
draining to 30cc
>With fully soaked
wound dressing
>With intact and
patent pen rose drain
>Capillary refill of 1
second
>Unable to sit and
position to side lying
>With good skin turgor
A>Impaired skin
integrity related to
tissue trauma
secondary to
pyelolitothomy, right

EXPLANATION
Pyeololithotomy is the
removal of stone in the
kidneys. An incision is
made over the right
flank area. Incision and
removal of the stone
causes tissue to be
destroyed. The
resulting mechanical
trauma resulted to a
break to the continuity
of the skin resulting to
impaired Skin Integrity.
Reference: Porth, C. M.,
(2005).
Pathophysiology:
Concepts of Altered
Health

OBJECTIVES
STO> After 4
hours of quality
nursing
interventions,
patient will have
intact and dry
dressing.

INTERVENSTIONS

Dx:
Assess wound status
Establishes
(REEDA (redness, edema,
comparative baseline
ecchymosis, discharge and
providing opportunity
approximation)
for timely intervention.
Indicates wound status
and wound healing

Assess mobility status

To evaluate
actual/potential
impairment of
circulation to
extremities.

Assess wound dressing

To assess circulation
and ability of the
patient to ambulate.

Assess capillary refill and

skin turgor
LTO> After 3 days
ofquality nursing
interventions,
patient will be free
from infection.

RATIONALE

Tx:
Keep the wound area
clean and dry

Reinforce dressings and

wound coverings
Remove wet and wrinkled
linens promptly

To evaluate degree of
bleeding and
discharges from wound
To prevent from
harboring
microorganism and to
promote healing and
assist in the bodys
natural repair.
To protect the wound
and surrounding tissues
Moisture potentiates

EVALUATION
STO>Fully met if after
4 hours of quality
nursing interventions
patient will have intact
and dry wound
dressing.
Not met if after 4
hours of quality
nursing the patient will
have soaked wound
dressing

LTO> Goal fully met if

after 3 days of quality
nursing interventions
patient will be free
from infection as
manifested by no
fever, no itchiness at
the site, no pain, no
redness, no edema, no
ecchymosis and no
discharge at the site.
Goal not met if after 3
days of quality nursing
interventions the
patient will have
infection as
manifested by fever,
itchiness at the site,

 Assist in moving and

sitting of patient

Edx:
Encourage early
ambulation or mobilization
gradually as tolerated

skin breakdown
To prevent excessive
exertion that may
provide mechanical
force inhibiting wound
healing

Promotes circulation
and reduces risks
associated with
Encourage to optimum
immobility
nutrition including vitamins
such as vitamin C and E

Teach patient on proper

hygiene

Vitamin C and E provide

a collagen that
promotes wound
healing

To protect wound and

prevent it from
infection

pain, redness, edema,

ecchymosis and
discharge at the site.