ASSESSMENT EXPLANATION OF

THE PROBLEM
GOALS AND
OBJECTIVES
NURSING INTERVENTION RATIONALE EVALUATION
Subjective:
Hindi naman
sumasakit yong sugat
ko , pero nakakatakot
gumalaw kasi baka
bumuka. Tapos
tinanggal na din ung
dressing ng sugat ko

Objective:
No Bleeding
No complaints
of itchiness
No foul odor
No discharges
on the incision
site
Status post
excision
biopsy of
antero-lateral
neck mass
LEFT
With
histopathologi
c diagnosis
features acute
necrotizing
lymphadenitis
dated August
1, 2014
With Vital
Signs of: BP:
120/70
mmHg, PR: 69
bpm , RR: 21
cpm , T: 36.9 C

Nursing Diagnosis:
Microorganisms
entered the lymphatic
vessels and becomes
lymphatic fluid and
filters in the lymphatic
vessels. The filtering
process involves
cellular proliferation
and the lymph nodes
become enlarged and
inflamed
l
Surgical intervention
(biopsy)
l
Incision on the left
anterolateral part of
the neck
l
Surgery involves
cutting / penetration
of the skin surface and
skin layers
l
Injury or trauma on
the skin/ tissue is
inflicted
l
Impaired skin
integrity


REFERENCE:
Brunner and
Suddarth
(2008)Textbook of
Medical-Surgical
Nursing, 10th
Edition.
Goal: Achieve a
normal wound
healing

Long Term
Objective:
After 72 hours of
nursing
intervention the
patient will not
manifest:
Bleeding
Itchiness
Foul odor
Discharg
es on the
Incision
site

Short Term
Objective:
After 8 hours of
nursing
intervention the
patient will
manifest:
Clean and
dry
incision
site
Diagnostics
1. Observe incisions
periodically, noting
approximation of wound
edges, hematoma
formation and resolution,
and presence of bleeding
and drainage.
2. Assess client's nutritional
status. Refer for a
nutritional consult, and/or
institute dietary
supplements as necessary.

Therapeutics
1. Keep pt.s room clean



2. Maintain dryness of the
surgical site
3.
4. Maintains aseptic
technique in cleaning the
surgical site
5. Change soiled linens



6. Aminister oral drugs as
prescribed
a. Celecoxib 200 mg 1 cap
BID





b. Levofloxacin 75mg 1

Verifies status of healing,
provides for early detection
of developing complications
requiring prompt
evaluation and influencing
choice of interventions.

Inadequate nutritional
intake places individuals at
risk for skin breakdown and
compromises healing



Practicing good hygiene
decreases chance of
accumulation of
microorganisms
Moisture serves as a
medium for bacterial
growth.
Reduces nosocomial
infection

Microorganisms may
accumulate in a soiled
linens and may migrate to
the surgical site


CELEBREX is a nonsteroidal
anti-inflammatory drug that
exhibits anti-inflammatory-
inhibition of prostaglandin
synthesis, primarily via
inhibition of
cyclooxygenase-2 (COX-2),
Anti-infective that Inhibit
The patient
was
discharged
with
objectives fully
met as
evidenced by
no signs of
bleeding,
itchiness, foul
odor, and
discharges on
the incision
site, clean and
dry surgical
site.

Goal partially
met as
patients
wound is still
on the process
of healing.
Impaired Skin
integrity related to
Tissue trauma
secondary to Cervical
Lymphnode biopsy
Philadelphia:
Lippincott
Williams &
Wilkins.
tab OD
c. Phenoxymethylpenicill
in 250mg 1 cap BID




Educative :
1. Instructed to avoid
touching the surgical site



2. Instructed to avoid
strenuous activities



3. Instruct patient and
significant others to
practice hand washing
before touching the site.
4. Encouraged to increase
intake of foods rich in
vitamin c and proteins.
Increase oral fluid intake.



bacterial DNA synthesis
Phenoxymethylpenicillin,
commonly known as
penicillin V, is an antibiotic
useful for the treatment of a
number of bacterial
infections.

Transfer of microorganisms
may occur upon touching
the surgical site which may
delay wound healing.

Strenuous activities may
bring pressure to the
surgical site which gives the
possibility of dehiscence.

Good personal hygiene
prevents contamination of
the surgical site.

To provide a positive
nitrogen balance to aid in
skin/ tissue healing and
maintain good general
health.