ACTIVITY INTOLERANCE

Assessment
Data
Subjective
Data:
"nahihirapan
akong kumilos"
As verbalized by
the client.

Nursing Diagnosis
Activity
intolerance related
to presence of
surgical incision
secondary to

Scientific
Rationale
Impalement
injury epigastric
area

Exploratory
laparotomy

Goals and Objective

After 1 hour of
nursing
interventions, patient
will be able to
demonstrate in
physiological signs
of intolerance.

Nursing Intervention

Weak in
appearan
ce

Surgical incision

Limited
mobility
on lower
extremitie
s

Pain

Facial
grimace
when
moved

Pain upon
moving

After 1 day
of nursing
intervention
patient will
be able to
demonstrate
a decrease
physiological
by had a
great
strength on
lower
extremities

Encourage
adequate rest
period

Rest between
activities
provides time
for energy
conservation
and recovery

Encourage
frequent deep
breathing
exercise

Promotes
optimal chest
expansion

Promote
comfort
measure and
provide for
relief of pain

To enhance
ability to
participate in
activities

Encourage
alternating
activity with
rest

Explain the
importance of
bed rest in
treatment

Limited mobility

Activity

Evaluation

Objective Data:

Rationale

Minimized
exhausition
and helps
balance O2
supply and
demand

Bed rest is
maintained to
decrease

intolerance

metabolic
demand thus
conserving
energy

IMPAIRED TISSUE PERFUSSION

Assessment Data

Objective Data:
-

incision wound
at the middle
of the
abdominal
area
Facial grimace

Nursing Diagnosis
Impaired tissue
perfusion related
to disruption of
skin as evidence
by surgical
incision of
abdominal area
due to Exploratory
laparotomy
secondary to
impalement injury
epigastric area

Scientific Rationale

Goal and Objective

After 1 hour of
nursing intervention
patient will be able
to:

Vital signs

Participate in
prevention
measures
and treatment
program
Ability to
manage the
situation
Maintain
physical well
being.
able to
display timely
healing of
skin wounds
without
complications
.

Nursing Intervention
-

To assess the
client condition

Inspect skin on
daily basis and
observe for
changes.

Keep the area

clean, ,carefully
dress wound.

Render health
teaching on:
a. on how to
clean the
wound
properly
using
betadine

Rationale
-

To assess
the
causative
condition

To
determine
unusual
ties and
report it to
physicians
for prompt
treatment

To aware
from
infections

To have
knowledge
on how to
clean the

Evaluation

b. The
aseptic
technique

Encourage client
not to touch the
wound

wound
properly

To aware
from
infections

RISK FOR INFECTION

Assessment Data

Objective Data:

Exploratory
laparotomy
With dry
intact
dressing on
the surgical
site
Dirty nails

Vital signs was

taken:
RR 26

Nursing
Diagnosis
Risk for
infection
related to
surgical
incision
due to
Explorator
y
laparotom
y
secondary
to
impaleme
nt injury
epigastric
area

Scientific
Rationale
Impaleme
nt injury
epigastric
area

Explorator
y
laparotom
y

Surgical
incision

Objective
After 1 hour
of nursing
intervention
the patient
verbalized
ways in
preventing
infection/
contaminatio
n specially
proper hand
washing and
wound care

Nursing Intervention

Rationale

Assess client condition

To have a
baseline

Monitor vital signs

Elevation in
rates may
signal
infection

Assess operative site for

signs of infection

To provide
baseline data
for
comparison
and identify
need for
further
management

Evaluation
Within 1 hour
of nursing
intervention
the patient
will be able to
verbalized
ways in
preventing
infection/
contamination
specifically
proper hand
washing and
proper wound
care as
evidenced by:
good skin
integrity,

PR 75 bpm
T 36.2
BP 110/80 mmHg

May
provide
portal
entry for
pathogens
through:
inadequat
e aseptic
techniques
especially
in wound
dressing

May result
to infection

Instruct the patient in

good hand washing, nail
cutting and aseptic
wound care

Change linens as
necessary

Instruct patient to refrain

from touching/scratching
the operative site

To reduces
risk of spread
of bacteria

To prevent
growth of
microorganis
m on linens
and bed

To prevent
skin break
down and
contaminatio
n of operative
site

absence of
swelling,
redness and
pain on
operative site.

IMPAIRED SKIN INTEGRITY

Assessment
Data
Subjective:
"Hindi pa
masyado
magaling ang
sugat ko" as
verbalized by the
client
Objective:

Nursing
Diagnosis
Impaired skin
integrity related
to skin/tissue
trauma as
evidenced by the
surgical incision
at the midline of
abdominal
secondary to
impalement
injury epigastric

Scientific
Rationale

Objective

Nursing
Intervention

Monitor
vital signs

Assess
operative
site for
redness,
swelling,
loose
sutures, or
soaked

Rationale

Evaluation

S/P
Explorator
y
laparotom
y

With
surgical
incision at
the
midline of
abdominal

Vital signs was

taken:
RR 26
PR 75 bpm
T 36.2
BP 110/80
mmHG

area

dressing

XIII. Nursing Care Plan

Acute Pain
Assessment Data
Subjective:
" sumasakit parin
tong tyan ko " as
verbalized by the
client

Nursing
Diagnosis
Acute pain
related to
surgical incision
located at the
midline of
abdominal

Scientific
Rationale
impalement
injury epigastric
area

Objective
After 1 hour of
nursing
intervention the
patient will
demonstrate
use of

Nursing Intervention

Investigate
pain reports,
noting,
location,
duration
intensity

Rationale

Evaluation

Changes in
location or
intensity are not
uncommon but
may reflect
developing

After 1 hour of
nursing
intervention the
patient was
able to
demonstrate

Objective:

Facial mask
pain

Pain scale
of 7 out of
10

Guarding
behavior

Vital signs

secondary to
impalement
injury epigastric
area

blood vessel and

underlying tissue
injury

relaxation skills
and other
methods to
comfort.

(010 scale)

complications

Provide
comfort
measure like
back rubs,
deep
breathing and
Instruct in
relaxation or
visualization
exercises

Promotes
relaxation and
may enhance
patient's coping
abilities by
refocusing
attention

Move patient
slowly and
deliberately

Reduces
muscle tension
or guarding
which may help
minimize pain
movement

Provide for
individualized
physical
therapy or
exercise
program that
can be
continued by
the client after
discharge

Promotes
active, rather
that passive,
role and
enhances sense
control

stimulation of
receptors

release of
neurotransmitter
s

interpretation of
cerebral cortex
as pain

use of
relaxation skills
and other
methods to
promote
comfort.