Assessment Subjective: nihubag ang akong gi operahan mao nga gi admit ko pag follow up check up naku diri as verbalized

by the pt. Objective: -itchiness noted -injury on the skin layers -1day pot-op

Nursing Diagnosis Impaired skin integrity related to surgical repair (debridement)

Nursing Goal

After 8hrs. of nursing interventions, the patient will be able Scientific Basis: to maintain Pt. Had skin integrity infection on her and free from surgical site at any signs of right arm. infection. Surgical intervention which is debridement was done thrice to remove the dead tissue. Surgery involves cutting of skin surface and skin layers. Injury or trauma on the skin/tissue is inflicted. Because of the injury there in vasodilation to hurriedly send the nutrients in the body via bloodstream.

Nursing Intervention Independent: -Monitor pts. vital signs regularly.

Rationale

Outcome Criteria

Evaluation

-to note for any changes or abnormalities.

1-stable vital signs 2-slight changes in vital signs 3-abnormal changes in vital signs 1-stable vital signs with no signs of local infection 2-slight changes in vital signs 3-presence of signs of infection

-Monitor for systemic and localized signs and symptoms of infection.

-Elevated temperature, pulse, and respiration indicate systemic infection. Redness, swelling, and pain indicate localized infection. -First line defense against nosocomial infection.

-Provide meticulous aseptic care, maintaining good handwashing technique. -Inspect condition of wound.

1-no signs of infection 2-slight changes in vital signs 3-presence of infection

-Early identification of developing infections permits prompt intervention and prevention of further complication. -Adequate nutrition is essential for immune system formation and

1-dry wound, no sign of infection 2-slight redness of wound 3-infected wound

-Encourage sufficient nutritional intake.

1-pt. Takes adequate nutritional food 2-eats less than required nutritional intake

for the repair of damaged body tissues to provide protection against external pathogens. Dependent: -Administer antibiotic therapy as ordered. (Doxycycline, Clindamycin) -Antibiotic therapy should assist the body to destroy pathogens.

3-inadequate nutritional intake with delayed tissue healing

1-no signs of infection 2-slight changes in vital signs 3-presence of signs and symptoms of infection

Goal is met