ASSESSMENT

NURSING DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

Risk for infection related Subjective: Wound Evisceration to inadequate defenses secondary to surgical incision.

-after 8 hours of rendering nursing intervention patient will be able to understand causative factors, identify signs of infection , will achieve timely wound healing, be free of purulent drainage of erythema, be a febrile and free of infection

Independent:

-After 8 houirs of

Monitor v/s Inspect dressing and perform wound care.

To establish baseline data Moist from drainage can be source of infection

rendering nursing intervention, patient is expected to be free of infection as evidenced by normal signs of an absence of purulent drainage from wounds, incisions and tubes.

Assess clients ability go out to bed.

Early ambulation prevents thrombophlebitis and to hasten faster wound healing.

Assess what measures client feels would make her comfortable.

Comfort measures reduces stress and anxiety, elevate mood, and raise the pain threshold, thus enhancing therapeutic

effectiveness of analgesics and the clients control over and ability to tolerate pain.

Dependent - Medications given like analgesics and antibiotics.

reduce/control pain Medications aid in the faster healing of the wound, releases pain or discomfort and provides body resistance to infection.

NURSING CARE PLAN ASSESSMENT Subjective: Nasakit toy sugat ko as verbalized by the patient. Objective: Guarding behaviour Facial grimace Restlessness discomfort Pain Scale of 7/10;10 as the highest Fever T=38.2 oC Acute pain related to surgical incision secondary to as evidenced by guarding behaviour, facial grimace, restlessness, discomfort, pain scale of 7/10 and fever(T=38.2) After 1-2 hours of nursing intervention, the patient will demonstrate reduction of pain as would be manifested by decreased degree of guarding behaviour, facial grimace, restlessness, discomfort pain scale of 4/10, and absence of fever. NURSING DIAGNOSIS PLANNING IMPLEMENTATION Independent: Monitor Vital Signs. Monitor Pain Scale. To provide baseline data. To evaluate decrease degree of pain. To reduce pain. After 1-2 hours of nursing intervention, the patient demonstrated reduction of pain as evidenced by decreased degree of guarding behaviour, facial grimace, restlessness, discomfort, pain scale of 4/10, and absence of fever. Goal met. RATIONALE EVALUATION

Encourage deep breathing exercises. Provide divertional activities.

To divert perception to pain. To relieve pain.

Administer analgesics . Encourage ambulation. To hasten wound healing and to relieve discomfort.

DRUG STUDY Drug Cefuroxime Mechanism of Action Contraindication Interferes with bacterial cell Hypersensitivity to cephalosporin or wall synthesis and division by penicillins. binding to cell wall, causing Carnitine deficiency. cell to die. Active against gram negative and grampositive bacteria, with expanded activity against gram-negative bacteria. Exhibits minimal immunosuppressant activity. Adverse Effect CNS: headache, hyperactivity, hypertonia, seizyres GI: nausea, vomiting, diarrhea, abdominal pain, dyspepsia, pseudomembranous colitis GU: hematuria, vaginal candidiasis, renal dysfunction, toxic nephropathy Hematologic: hemolytic anemia, aplastic anemia, hemorrhage Hepatic: hepatic dysfunction Metabolic: Hyperglycemia Skin: erythema multiforme, Stevens- Johnson syndrome Other: allergic reaction, fever, anaphylaxis Nursing Responsibilities Monitor patient for lifethreatening adverse effects, including anaphylaxis, StevensJohnson syndrome, and pseudomembranous colitis. Monitor neurologic status, particularly for signs of impending seizures. Monitor kidney and liver function test results and I&O Monitor CBC with differential and prothrombin time; watch for signs and symptoms of blood dyscrasias. Monitor temperature; watch for signs and symptoms of superinfection. Advise patient to report immediately rash or bleeding tendency. Instruct patient to take drug with food every 12 hours as prescribed.

Pharmacologic Class: 2nd Generation cephalosporin Therapeutic Class: Anti- Infective