Cues Nursing Rationale Objectives Intervention Rationale Evaluation

Diagnosis s
Subjective Impaired Surgical Short term: Independen
Short term:
: skin integrity Intervention After 20-30 minutes t:
After 30 minutes of
“Medyo related to (Cholecystectom of nursing  Keep the  Moistur
nursing intervention,
malaki nga surgical y) intervention, the area es
the patient was able
yung hiwa incision on patient will be able clean and harbors
to:
na ginawa the Right Incision on the to: dry bacteria
1. Demonstrate
sa tiyan ko, Upper Right upper 1. Demonstrate and
proper way of
nasa Quadrant of quadrant to Proper way of pathoge
wound care
5inches din the abdomen remove the wound care n
and proper
kaya baka as evidence disease tissue and proper
dressing
matagalan with (Surgical dressing
 GOAL FULLY
ang dressing on the  Splintin
MET
paghilom Subjectiv right upper  Provide a g
ng sugat e: quadrant of her splinting provide
2. Understand
ko.” As the “Medyo abdomen) 2. Understand pillow s
the
patient malaki the support
importance of
verbalized nga yung Surgery involves importance of to the
caring the
a days hiwa na cutting caring the area ,
incision site
after the ginawa sa /penetration of incision site minimizi
as she
surgery. tiyan ko, skin surface and ng
verbalized
Feb, 17, nasa skin layers discomf
 2010. 5inches ort and “Iniingatan ko ang
din kaya Injury or trauma encoura sugat ko na wag
Objective: baka on the skin/ ging the maimpeksyon.”
 Surgical matagalan tissue is inflicted patient
dressing ang to move  GOAL FULLY
on the paghilom Because of the and MET
right ng sugat injury there in cough
upper ko.” As the vasodilatation to Long term:
quadrant patient hurriedly send Long term: After 4 days of
of her verbalized the nutrients in After 3-4 days of nursing
abdome a days the body via nursing intervention, intervention, the
n after the bloodstream the patient will be patient was able to:
 Redness surgery. (Redness on able to:  Freque 1. Maintained the
on the Feb, 17, the skin 1. Maintain the  Inspect nt wound intact as
skin 2010. surrounding wound intact. the assess verbalized “Di
surround the incision incision ment na gaanung
ing the Objective sight) every can masakit yung
incision : shift detect sugat ko.”
sight  Surgical Because of using early
 Disruptio dressing vasodilatation REEDA signs  GOAL

n of the on the there is redness 2. Shows sign of (redness, and PARTIALLY MET

skin right upper on the wound edema, sympto

 surface quadrant surrounding healing (dry ecchy ms of 2. Shows dry and
(epiderm of her tissue on the and intact mosis, infectio intact wound
is) abdomen injury site wound and discharg n and initial
 Injury on  Redness initial scaring) e, and scaring
the skin on the Reference: approxim
layers skin Principles of ation)  GOAL
Med-Surg Vol. 1
(dermis) surroundin 4th edition by PARTIALLY
g the Lemone and  Carefully  To MET
Burke
incision 3. No redness dress prevent
sight on the wounds infectio 3. No redness on
 Disruption surrounding n to the surrounding
of the skin area. area.
surface
(epidermis  Inform  To  GOAL
) patient of increas PARTIALLY
 Injury on the e MET
the skin purpose complia
layers of self- nce
(dermis) care
practices
 To
 Use protect
 appropriat wound
e barrier and or
dressings, the
wound surroun
coverings, ding
drainage area.
appliance
and skin
protective
agents for
open
wounds.
 To
 Provide provide
optimum a
nutrition positive
including nitroge
vitamins n
such as balance
Vit. C and to aid in
E. skin/tiss
ue
 healing
and
maintai
n
general
good
health.

 Encourag  To
e early promot
ambulatio e
n or circulati
mobilizati on and
on. reduces
risks
associa
te with
 immobil
ity.

 Moistur
 Limit or
e
avoid use
potentia
of plastic
tes skin
material.
breakd
own.

 To
 Increase
promot
protein
e
intake.
wound
healing.

Dependent:
 To
 Administe
inhibit
r synthe
prophylac sis of
tic bacteri
antibiotics al cell
as wall,
indicated causin
(Ceftriaxo g cell
ne death
Sodium) 1
gm IVT
q12 for 2
doses