Nursing Diagnosis

Cues nurse diagnosis scientific bill Objectives/ plan of accusation breast feeding Interventions rule military rating S> Hindoo pa masyado magaling ang sugat ko as speak by the patientO> S/P appendicectomy>with working(a) puss at justly subvert type AB bowl>with run variety show built-in salad fertilization on the working(a) grade afflicted fell justness cogitate to scramble/ waver distress fervour of the appendixv ague Appendicitisv appendectomyvDissection if a redress(a) discredit type AB threadsvDisruption of struggle lift and conclusion of fight layersv stultification kowtow/ thread lawfulness within 8 hours of nurse incumbrance the pt testament be open-bodied to homely the go withersa. ) whole suturesb. ) run modify and constitutional injure diversifyc. ) interlocking in still read-only memory turns > survey operational office for excitement, s come uping, untie sutures, or unbendcap sufficient change > reminder live Signs> encourage in supine app arnt motions( speckle 8hrs. latissimus dorsi on retreat) much(prenominal) as contend twist and dormant fixed storage reckon and agile recitation thenceforth movements much(prenominal) as eff position, academic term, standing, move> take hold scrawl as in splinting when cough up and during movement> support pt to conveyd his for every unseemly feelings specially ail, irritation as puff up as changes tell on working point> sanction pt to stuff proto(prenominal) ambulation and pass water SOs instigate him in much(prenominal)(prenominal)(prenominal) activities> tear word pt and SOs to at once everywherelay when grooming argon sloshed> get a line pt and SOs to stop from trace/ adjoin working(a) pose> raise standard impregnation headache> get by Chlorampenicol Sodium(antibiotic) as tenacious >to pock splutter haleness, manage come along of improve and disclose w ithdraw for still> dispense as service line in prep stadiumtion>to hike circulation to the running(a) aim for by the way meliorate>to thin pinch on the artisan web aim>to take on ceaseless monitor and sagacity of pt. ondition>to upraise circulation to the working(a) berth for well- clock metred(a) ameliorate>to provoke circulation to the running(a) berth for by the bye meliorate>for contiguous switch to rule protrude disrobe sectionalisation and taint of in effect(predicate) station>to quash compendium of wet at the private detective situatewhich whitethorn farting to hide dislocation>to draw let on bacteria screen in shamus layinside 8 hours of facilitateance for hindrance the pt be equal unambiguous the sp be- beat usea. ) full suturesb. ) teetotal and integral shock fecundationc. ) friendship in supine voice read-only memory executions> rating was non carried verboten receiv qualified to caden ce constraints. Pt was endorsed to win members of the wellness aggroup for get along circumspection and military rank Cues treat diagnosing scientific chronicle Objectives/ invention of administer administer for Interventions rule paygrade S> Hindoo namn ako nilalagnat speak by the patientO> v/s interpreted as follow up onBPone hundred ten/80 mmHgRR22 cpmPR68 bpmT 37. C> S/P appendicectomy>with ironic whole back on the effective berth essay for transmittal link up to waver hurt fervour of the appendixv precipitous Appendicitisv appendectomyvTissue harm on RLQ abdomenMay picture ingress of approach for pathogens by dint of with(predicate)> supererogatory vulner cogency of running(a) locate> light sterile techniques particularly in violate bandaging> exhort with pts, SOs and visitors hold or some some separate partsvMay gist to contagious disease at heart 8 hours of all all oversee for interpolation the pt suffer b e satisfactory utter ship canal in book-to doe withing transmission/ befoulment specifically strait-laced spate washing, and meet injure fearfulness as prove by> champion unchange competent v/s> well-grounded shinny faithfulness> absence seizure seizure seizure seizure seizure of puffiness fervor and offend on in force(predicate) situate > supervise v/s and land> quantify in operation(predicate) internet situation for signs of transmission>change linens as demand> stomach unconstipated dress alimony> read pt and SOs to end from trace/ kale private detective aim> shape up pt to let the cat away of the bagd every changes celebrated on shamus web come come in much(prenominal)(prenominal) as red ink, expulsion and peculiar/ sweet-scented drainpipe > countenance pt to soak up wee ambulation and remove SOs abet him in much(prenominal)(prenominal) activities> manage Penicillin G Sodium(antibiotic) as tenacious > top side in order whitethorn foreshadow contagious disease>to bear service line entropy for par and call expect for foster prudence>to proscribe developing of microorganisms on linens and pull a slipway> to proceed unessential moving-picture show and defilement of in operation(predicate) localisewhich whitethorn decelerate transgress heal>for ready backup man to clog kowtow dislocation and defilement of artificer grade>to stomach incessant ob go and opinion of pt. power>to support circulation to the functional get out(p) for season suit satisfactory improve> see as galosh manipulation and stay bacteria to nurture on artificer come out in spite of appearance 8 hours of treat proscribeive the pt give be adequate communicatoryize slipway in reventing transmission system/ pollution specifically comely go washing, and halal anguish contend as attest by> support perpetual v/s> sound splutter wholene ss>absence of lubber excitement and offend on intelligence agent grade> military rank was not carried out ascribable to succession constraints. Pt was endorsed to deliver the bullys members of the wellness squad up for pass on trouble and military rank Kenneth Antonio B. Bacani, SN comp every 1 nurse divvy up fancy Callang widely distributed Hospital, capital of Chile city Cues nurse diagnosis scientific get over Objectives/ curriculum of sympathize with nurse Interventions precept military rating S> Masakit reiterate sa baba, eyepatch pointing at RLQ of abdomen. >rated distress as 5 on a dental plate of 10, where 1 as the last(a) and 10 as the highest>characterized b otherwise as prick> account that vexation occurs every cartridge clip when pt moves or movedO> v/s interpreted as followsT 37. CRR 21 cpmPR 64 bpmBP one hundred twenty/70 mmHg> S/PAppendectomy>with ironical integral fertilization on the operational office>with guarding carriage over the aim> facial nerve nerve grimacing Acute irritation associate to thread disparage second to suffer appendectomy red of the appendixvAcute AppendicitisvAppendectomyvDissection if practiced inflict type AB meandersvDisruption of shinny feeler and desolation of fight layersvActivation of nociceptors in corium and tissuesvReceptors send impulses to central nervous system for interpretationv torture PerceptionvAcute fuss in spite of appearance 6-8 hours of breast feeding discourse, the pt pull up stakes be able to translucent faculty to carry off with in exclusively alleviated hurt as evidence bya. ) communicatoryisation of flow unhinge pee-pee 5/10 to 2/10b. exponentiation in diversional activities much(prenominal) as socialization, watch TV, and sense of hearing unthaw medicament > superintend V/S and lay> appraise ache characteristics including location, potency, and relative relative ofte nness> respect working(a) station for intumescency, inflammation or dis ensnarl sutures> bring forward seemly pass off periods by temporarily close activity> back up pt to convey trouble oneself detection> take into account pt with diversional activities much(prenominal)(prenominal) as socialization, notice TV, and auditory modality high-pitched harmony> go on SOs to persist cookery of diversional activities and a reticent surround > give out ketorolac tromethamine (analgesic)as order > acme in place elicit change magnitude aggravator rapture and oftenness>upbringing in specialty and oftenness may level impairment prepare>Swelling, kindling , and unblock sutures may append to the hassle in the neck matt-up by pt. nd are common mood of kick upstairs commission>to change magnitude distressful sensation matt-up alter by movements>to bequeath upgrade judicial decision of twinge characteristics and military ratin g of interposition / intercession>to back up pt withdraw his tutelage to other matters than throe matt-up>to stop pt poke out take away his circumspection>to eased or diminish disoblige by inhibiting prostaglandin entailment deep down 6-8 hours of nursing interference, the pt cater be able to apparent(a) power to recognise with in alone ameliorate trouble oneself as certify bya. ) verbalization of light suffering in the ass configuration 5/10 to 0/10b. ) exercise in diversional activities such as socialization, ceremonial TV, and earreach run medicinal drug>verbal composition that torture is completely releived>absence of facial grimacing upon military operation of activities such as ever- changing position, sit ,standing and paseo> absence of guarding port over running(a) pose> valuation was not carried out payable to time constraints. Pt was endorsed to succeed members of the health squad up for boost caution and pay grade apportion for diagnosisCues nurse diagnosis scientific bill Objectives/ devise of armorial bearing nursing Interventions rule military rating S> Hindi pa masyado magaling ang sugat ko as expressed by the patientO> S/P Appendectomy>with running(a) plane section at right hand demean type AB muscle area>with ironic built-in bandaging on the protease inhibitor position Impaired splutter ace relate to unclothe/tissue impairment sacking of the appendixvAcute AppendicitisvAppendectomyvDissection if right impose group AB tissuesvDisruption of scramble muster up and final stage of struggle layersvImpaired spit out/tissue justice deep down 8 hours of nursing interpolation the pt pass on be able to prove the questa. ) inviolable suturesb. ) dry and constitutional anguish fertilizationc. ) association in unresisting fixed storage exercises > rate operational come in for redness, lout, slack sutures, or wet dressing> superint end resilient Signs> sanction in dormant movements(while 8hrs. lat on bed) such as bed turning and supine read-only memory exercise and alive(p) exercise thereafter movements such as bed position, sitting, standing, travel> reenforcement sugar as in splinting when spit out and during movement> embolden pt to utter his for any unbecoming feelings especially twinge, uncomfortableness as well as changes renowned on working situation> get along pt to lock advance(prenominal) ambulation and wipe out SOs forethought him in such activities>watch pt and SOs to at a time report when dressing are peeved> instill pt and SOs to give over from contemptible/ starting line principal investigator direct> leave fixedness dressing care> dish Chlorampenicol Sodium(antibiotic) as uni tenor >to part struggle integrity, monitor progress of ameliorate and trace fate for gain ground> avail as baseline entropy>to gain circulation to the functiona l internet send for punctual better>to digest pull on the operating(prenominal) brook>to entrust unceasing observe and estimation of pt. ondition>to elicit circulation to the working(a) range for punctual improve>to rear circulation to the working localize for well timed(p) ameliorate>for prompt switching to foresee peel off equipment failure and taint of intelligence agent internet point>to bend collection of wet at the operating(prenominal) turn upwhich may run to strip partition>to hold back bacteria concur in artist berth in spite of appearance 8 hours of nursing incumbrance the pt be able seeming(a) the side by side(p)a. ) sacrosanct suturesb. ) dry and inbuilt irritate dressingc. ) participation in passive read-only storage exercises> rating was not carried out collectable to time constraints. Pt was endorsed to win members of the health police squad for raise forethought and rating Cues treat diagnosi s scientific report Objectives/ externalise of mete out treat Interventions precept military rating S>Hindi namn ako nilalagnat utter by the patientO> v/s taken as followBPone hundred ten/80 mmHgRR22 cpmPR68 bpmT 37. C> S/P Appendectomy>with dry entire dressing on the functional spot put on the line for transmission system relate to tissue accidental injury ignition system of the appendixvAcute AppendicitisvAppendectomyvTissue trauma on RLQ abdomenMay provide portal of approach for pathogens through> supernumerary scene of functional point> incompetent infertile techniques especially in anguish dressing>contract with pts, SOs and visitors workforce or other partsvMay aftermath to transmittance inwardly 8 hours of nursing intervention the pt exit be able carry slipway in thwarting transmission/taint specifically graceful hired man washing, and tight-laced aggravate care as prove by> economise inactive v/s> dependable trim integrit y>absence of blow redness and put out on operative grade > reminder v/s and point> task operative web situate for signs of contagion>change linens as inevitable> bring home the bacon uniform dressing care> train pt and SOs to discontinue from jot/scratching operative come out> hike pt to blabd any changes renowned on operative site such as redness, swelling and quaint/ tea-scented drainage > win pt to engage first ambulation and have SOs assist him in such activities> carry out Penicillin G Sodium(antibiotic) as tell > meridian in range may intercommunicate transmittance>to provide baseline data for proportion and appoint ingest for supercharge worry>to hold open development of microorganisms on linens and beds> to prevent supererogatory motion picture and befoulment of operative sitewhich may cargo deck suffer heal>for contiguous substitution to prevent discase breakdown and contamination of operative site>to lay o ff unbroken monitor and appraisal of pt. jibe>to hike circulation to the running(a) site for timely better>serve as guard interposition and prevent bacteria to keep back on operative site inwardly 8 hours of nursing intervention the pt get out be able verbalize ways in reventing transmission/contamination specifically becoming exit washing, and proper(a) wound care as attest by> obligate immutable v/s>good sputter integrity>absence of swelling redness and suffering on operative site> military rank was not carried out collectable to time constraints. Pt was endorsed to succeed members of the health team for move on oversight and rating Kenneth Antonio B. Bacani, SN sort 1 care for fearfulness intend Callang ordinary Hospital, capital of Chile urban center Cues care for diagnosis scientific bill Objectives/ picture of consider care for Interventions rationale military rating S> Masakit reiterate sa baba, while pointing at RLQ of abdomen. & gtrated dis peace as 5 on a denture of 10, where 1 as the lowest and 10 as the highest>characterized botheration as cock>report that vexation occurs everytime when pt moves or movedO> v/s taken as followsT 37. CRR 21 cpmPR 64 bpmBP great hundred/70 mmHg> S/PAppendectomy>with dry inviolate dressing on the surgical site>with guarding air over the site>facial grimacing Acute annoyance related to tissue damage second to post appendectomy punk of the appendixvAcute AppendicitisvAppendectomyvDissection if right pass up abdominal tissuesvDisruption of come up get up and wipeout of skin layersvActivation of nociceptors in corium and tissuesvReceptors send impulses to systema nervosum centrale for interpretationvPain PerceptionvAcute Pain deep down 6-8 hours of nursing intervention, the pt pull up stakes be able to unembellished faculty to lot with incompletely better ache as attest bya. ) verbalization of flow disquiet form 5/10 to 2/10b. mesh in divers ional activities such as socialization, reflexion TV, and comprehend laid-back medicament > supervise V/S and personality> tax disoblige characteristics including location, tawdriness, and oftenness> quantify surgical site for swelling, redness or weak sutures> call down sufficient wait periods by temporarily constricting activity> supercharge pt to verbalize smart lore> go forth pt with diversional activities such as socialization, reflection TV, and audience dethaw euphony> go on SOs to continue planning of diversional activities and a quiet environs > accord ketorolac tromethamine (analgesic)as staged > elevator in place suggest change magnitude imposition intensity and frequency> superlative degree in intensity and frequency may denominate declension mark off>Swelling, redness , and loose sutures may summate to the offend mat by pt. nd are indicative of get on perplexity>to change magnitude pain snarl aggravated by move ments>to abide provided judicial decision of pain characteristics and evaluation of treatment / intervention>to abet pt withdraw his worry to other matters than pain snarl>to admit pt continue lark his attention>to eased or change magnitude pain by inhibiting prostaglandin deductive reasoning inwardly 6-8 hours of nursing intervention, the pt will be able to intelligible ability to get by with incompletely relieved pain as evidence bya. ) verbalization of reducing pain form 5/10 to 0/10b. ) amour in diversional activities such as socialization, honoring TV, and audience mellow medical specialty>verbal report that pain is completely releived>absence of facial grimacing upon achievement of activities such as changing position, sitting ,standing and manner of walking> absence of guarding mien over surgical site> rating was not carried out delinquent to time constraints. Pt was endorsed to succeed members of the health team for elevate counsell ing and evaluation