Subjective: Ineffective STG: Independent Patient is
– none airway After 4 hours of -Monitor vital -To establish a expected to be clearance nursing signs baseline data free of Objective: related to intervention, infection, as surgery patient will be -Inspect dressing -Moist from evidenced by anesthesia able to and perform drainage can be a normal vital Temp: 36.4˚C understand wound care source of infection signs and PR: 55 causative absence of RR:22 factors, identify - Monitor white - Rising WBC purulent CR:58 signs of blood count (WB indicates body’s drainage from BP:110/70 infection and efforts to combat wounds, report them to pathogens; incisions, and health care normal values: tubes. provider 4000 to 11,000 accordingly. mm3 - Monitor LTG: Elevated -these are signs After 2-3 days temperature, of infection of nursing Redness, intervention, swelling, patient will increased pain, achieve timely or purulent wound healing, drainage at be free of incisions purulent drainage or - Wash hands -Friction and erythema, be and teach other running water afebrile and be caregivers to effectively remove free of infection. wash hands microorganisms before contact from hands. with patient and Washing between between procedures procedures with reduces the risk patient. of transmitting pathogens from one area of the body to another
- Encourage fluid - Fluids promote
intake of 2000 ml diluted urine and to 3000 ml of frequent emptying water per day of bladder; (unless reducing stasis of contraindicated). urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).
- Encourage - These measures
coughing and reduce stasis of deep breathing; secretions in the consider use of lungs and incentive bronchial tree. spirometer. When stasis occurs, pathogens can cause upper respiratory infections, including Independent: pneumonia. – Administe r -Antibiotics have antibiotics bactericidal effect that combats pathogens PRIORITIZED PROBLEM 1.Fluid volume deficit r/t post surgical fluid restriction
2.altered tissue perfusion r/t immobility during and after surgery
Alternative Medicine Bible (2 Books in 1): HERBAL ANTIVIRALS NATURAL REMEDIES FOR EMERGING AND RESISTANT VIRAL INFECTIONS + HERBAL MEDICINE FOR BEGINNERS : The Ultimate Guide Guide to Healing Common Ailments