Nursing Diagnosis Argumentative Essay
Within 8 hours of nursing intervention the pt will be able to manifest the following:
- intact sutures
- dry and intact wound dressing
- participation in passive
ROM exercises
Assess operative site for redness, swelling, loose sutures, or soaked dressing; Monitor Vital Signs; Assist in passive movements (while 8hrs. lat on bed) such as bed turning and passive ROM exercise and active exercise thereafter movements such as bed position, sitting, standing, walking; Support incision as in splinting when coughing and during movement;
Encourage pt to verbalized his for any untoward feelings especially pain, discomfort as well as changes noted on operative site;Encourage pt to engage early ambulation and have SO’s assist him in such activities;Instruct pt and SO’s to immediately report when dressing are soake; Instruct pt and SO’s to refrain from touching/scratching operative sitу; Provide regular dressing care; Administer Chlorampenicol Sodium(antibiotic) as ordered; to check skin integrity, monitor progress of healing and identify need for further; Serve as baseline data to promote circulation to the surgical site for timely healing; to reduce pressure on the operative site; to allow continuous monitoring and assessment of pt. ondition to promote circulation to the surgical site for timely healinп;to promote circulation to the surgical site for timely healing; for immediate replacement to prevent skin breakdown and contamination of operative site to avoid accumulation of moisture at the operative sitewhich may lead to skin breakdownб to prevent bacteria harbor in operative site
Tissue trauma on RLQ abdomen
May provide portal of entry for pathogens through
- unnecessary exposure of surgical site
- nadequate aseptic techniques especially in wound dressing
- contract with pt’s, SO’s and visitors hands or other partsv
- may result to infection
Within 8 hours of nursing intervention the pt will be able verbalize ways in preventing infection/contamination specifically proper hand washing, and proper wound care as evidenced by; maintain stable; good skin integrity; absence of swelling redness and pain on operative site; Monitor v/s and record assess operative site for signs of infection; change linens as necessary; Provide regular dressing care; Instruct pt and SO’s to refrain from touching/scratching operative site;
Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage; Encourage pt to engage early ambulation and have SO’s assist him in such activities; Administer Penicillin G Sodium(antibiotic) as ordered; Elevation in rates may signal infection; to provide baseline data for comparison and identify need for further management; to prevent growth of microorganisms on linens and beds> to prevent unnecessary exposure and contamination of operative sitewhich may delay wound healing; for immediate replacement to prevent skin breakdown and contamination of operative site; to allow continuous monitoring and assessment of pt. condition; to promote circulation to the surgical site for timely healing; serve as prophylactic treatment and prevent bacteria to harbor on operative site
Swelling, redness , and loose sutures may contribute to the pain felt by pt. nd are indicative of further management; to lessen pain felt aggravated by movements; to allow further assessment of pain characteristics and evaluation of treatment/intervention, help pt divert his attention to other matters than pain felt; to allow pt continue divert his attention; to relieved or lessen pain by inhibiting prostaglandin synthesis
Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced by) verbalization of decrease pain form 5/10 to 0/10b. ) engagement in diversional activities such as socialization, watching TV, and listening mellow music verbal report that pain is completely releived; absence of facial grimacing upon performance of activities such as changing position, sitting ,standing and walking; absence of guarding behavior over surgical site; Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation|
