Nursing Diagnosis Free Essays

Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| Sgt; â€Å" Hindi pa masyado magaling ang sugat ko† as verbalized by the patientOgt; S/P Appendectomygt;with surgical incision at right lower abdominal areagt;with dry intact dressing on the surgical site| Impaired Skin Integrity related to skin/tissue trauma| Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvImpaired skin/tissue integrity| Within 8 hours of nursing intervention the pt will be able to manifest the following:a. ) intact suturesb. ) dry and intact wound dressingc. We will write a custom essay sample on Nursing Diagnosis or any similar topic only for you Order Now ) participation in passive ROM exercises| gt;Assess operative site for redness, swelling, loose sutures, or soaked dressinggt;Monitor Vital Signsgt;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, walkinggt; Support incision as in splinting when coughing and during movementgt; Encourage pt to verbalized his for any untoward feelings especially pain, discomfort as well as changes noted on operative sitegt;Encourage pt to engage early ambulation and have SO’s assist him in such activitiesgt;Instruct pt and SO’s to immediately report when dressing are soakedgt;Instruct pt and SO’s to refrain from touching/scratching operative sitegt;Provide regular dressing caregt;Administer Chlorampenicol Sodium(antibiotic) as ordered| gt;to check skin integrity, monitor progress of healing and identify need for furthergt; Serve as baseline datagt;to promote circulation to the surgical site for timely healinggt;to reduce pressure on the operative sitegt;to allow continuous monitoring and assessment of pt. onditiongt;to promote circulation to the surgical site for timely healinggt;to promote circulation to the surgical site for timely healinggt;for immediate replacement to prevent skin breakdown and contamination of operative sitegt;to avoid accumulation of moisture at the operative sitewhich may lead to skin breakdowngt;to prevent bacteria harbor in operative site| Within 8 hours of nursing intervention the pt be able manifest the following:a. ) intact suturesb. ) dry and intact wound dressingc. ) participation in passive ROM exercisesgt;Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation| Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| Sgt;†Hindi namn ako nilalagnat† verbalized by the patientOgt; v/s taken as follow:BP:110/80 mmHgRR:22 cpmPR:68 bpmT: 37. Cgt; S/P Appendectomygt;with dry intact dressing on the surgical site| Risk for infection related to tissue trauma| Inflammation of the appendixv Acute AppendicitisvAppendectomyvTissue trauma on RLQ abdomenMay provide portal of entry for pathogens through:gt;unnecessary exposure of surgical sitegt;inadequate aseptic techniques especially in wound dressinggt;contract with pt’s, SO’s and visitors hands or other partsvMay 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:gt;maintain stable v/sgt;good skin integritygt;absence of swelling redness and pain on operative site | gt;Monitor v/s and recordgt;assess operative site for signs of infectiongt;change linens as necessarygt;Provide regular dressing caregt;Instruct pt and SO’s to refrain from touching/scratching operative sitegt; Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage gt;Encourage pt to engage early ambulation and have SO’s assist him in such activitiesgt;Administer Penicillin G Sodium(antibiotic) as ordered| gt;Elevation in rates may signal infectiongt;to provide baseline data for comparison and identify need for further managementgt;to prevent growth of microorganisms on linens and bedsgt; to prevent unnecessary exposure and contamination of operative sitewhich may delay wound healinggt;for immediate replacement to prevent skin breakdown and contamination of operative sitegt;to allow continuous monitoring and assessment of pt. conditiongt;to promote circulation to the surgical site for timely healinggt;serve as prophylactic treatment and prevent bacteria to harbor on operative site| Within 8 hours of nursing intervention the pt will be able verbalize ways in reventing infection/contamination specifically proper hand washing, and proper wound care as evidenced by:gt;maintain stable v/sgt;good skin integritygt;absence of swelling redness and pain on operative sitegt;Evaluation was not carried out due to time constraints. Pt was endorsed to succeeding members of the health team for further management and evaluation| Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago City Cues| Nursing Diagnosis| Scientific Explanation| Objectives/Plan of Care| Nursing Interventions| Rationale| Evaluation| Sgt; â€Å"Masakit ditto sa baba†, while pointing at RLQ of abdomen. gt;rated pain as 5 on a scale of 10, where 1 as the lowest and 10 as the highestgt;characterized pain as prickinggt;reported that pain occurs everytime when pt moves or movedOgt; v/s taken as followsT: 37. CRR: 21 cpmPR: 64 bpmBP: 120/70 mmHggt; S/P Appendectomygt;with dry intact dressing on the surgical sitegt;with guarding behavior over the sitegt;facial grimacing| Acute pain related to tissue damage 2nd to post appendectomy| Inflammation of the appendixvAcute AppendicitisvAppendectomyvDissection if right lower abdominal tissuesvDisruption of skin surface and destruction of skin layersvActivation of nociceptors in dermis and tissuesvReceptors send impulses to CNS for interpretationvPain PerceptionvAcute Pain| Within 6-8 hours of nursing intervention, the pt will be able to manifest ability to cope with incompletely relieved pain as evidenced bya. ) verbalization of decrease pain form 5/10 to 2/10b. engagement in diversional activities such as socialization, watching TV, and listening mellow music| gt; Monitor V/S and recordgt;Assess pain characteristics including location, intensity, and frequencygt;Assess surgical site for swelling, redness or loose suturesgt;Promote adequate rest periods by temporarily limiting activitygt;Encourage pt to verbalize pain perceptiongt;Provide pt with diversional activities such as socialization, watching TV, and listening mellow musicgt;Encourage SO’s to continue provision of diversional activities and a quiet environment gt;Administer Toradol (analgesic)as ordered | gt;Elevation in rates suggest increased pain intensity and frequencygt;Elevation in intensity and frequency may indicate worsening conditiongt; Swelling, redness , and loose sutures may contribute to the pain felt by pt. nd are indicative of further managementgt;to lessen pain felt aggravated by movementsgt;to allow further assessment of pain characteristics and evaluation of treatment / interventiongt;to help pt divert his attention to other matters than pain feltgt;to allow pt continue divert his attentiongt;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 bya. ) verbalization of decrease pain form 5/10 to 0/10b. ) engagement in diversional activities such as socialization, watching TV, and listening mellow musicgt;verbal report that pain is completely releivedgt;absence of facial grimacing upon performance of activities such as changing position, sitting ,standing and walkinggt; absence of guarding behavior over surgical sitegt;Evaluation was not carried out due to time co nstraints. Pt was endorsed to succeeding members of the health team for further management and evaluation| How to cite Nursing Diagnosis, Papers Nursing Diagnosis Free Essays Nursing Diagnosis Nursing diagnosis is a medical concept that is becoming a commonly applied approach in the aspect of healthcare and medical service. This aspect mainly focuses on the presumptive and initial health and medical analysis conducted by the nursing class of healthcare serving as an overview basis and diagnosis for the following treatment and medical application. Aiding as a primary health analysis, nursing diagnosis actually becomes the springboard for further treatment and observation by giving the healthcare nursing a professional idea about the condition and the needed healthcare service of the patient. We will write a custom essay sample on Nursing Diagnosis or any similar topic only for you Order Now Thus, this healthcare concept can be considered as a synonymous to the concept of applying first aid only on a broader and more concise aspect. (Carpenito-Moyet 2007) The concept of nursing diagnosis mainly originates from the principle of maximizing the efficiency of healthcare service especially on institutions providing one. In this aspect, the service of medical personnel mainly the physicians and the doctors can actually be efficiently maximizing by distributing tasks that are dispensable on their level by utilizing other healthcare personnel for diagnosis and initial treatment aspects. On this account, other professional healthcare service has been seek primarily the nursing department wherein they have been titled for the duty of initial diagnosis and treatment thus giving the medical practitioners an overview of the healthcare conditions of the patients. In turn, medical diagnosis has been effectively focused on conditions specifically in need of their specialty. Thus, the establishment of nursing diagnosis has significantly maximized the healthcare capacity of the general area of service by effectively dividing and efficiently classifying the healthcare conditions of sum of their patients. Carpenito-Moyet 2007) The structure of nursing diagnosis is mainly classified in five general aspect mainly based on the nature and the intensity of the healthcare condition. This structural classification is set based upon the guidelines determined by the North American Nursing Diagnosis Association-International (NANDA-International) which are namely actual diagnosis, risk d iagnosis, possible diagnosis, syndrome diagnosis, and wellness diagnosis. Each classification has their own focused aspect thus, nursing diagnosis collective encompassed all of the aspects and possibilities of a healthcare situation. (Carpenito-Moyet 2007) Nursing diagnoses also varies according to the health pattern and the determined general nature of the scenario. Nursing diagnoses can vary from relating to health perception and management, metabolic nutrition, conditional elimination, management of physical activities and rest, and other humanistic aspect relating to health condition and human physiology. Commonly, nursing diagnosis takes its main significance in its application concerning the nursing healthcare plan wherein the standardized statement derived from the initial observation and analysis will actually and dominant affect the healthcare plan to be applied for the patient’s condition. (Carpenito-Moyet 2007) Generally, nursing diagnosis is a standardized healthcare statement regarding the patient’s condition thus, determining the appropriate nursing care and medical approach to be applied in the aspect of healthcare service. This statement stands out as the product of initial observation and analysis of the patient specifying the most needed healthcare treatment and the potentials of his or her condition. Thus, nursing diagnosis becomes a significant element in the healthcare practice and application because it efficiently develops the aspect of healthcare service and it generally answers the required specific aspect of the treatment and attention needed. (Carpenito-Moyet 2007) References Carpenito-Moyet, Lynda Juall (2007). Nursing Diagnosis: Application to Clinical Practice. Lippincott Williams Wilkins. 11th Edition. How to cite Nursing Diagnosis, Essay examples