Vous êtes sur la page 1sur 5

ASSESSMENT

NURSING DIAGNOSIS
RATIONALE
PLANNING
NURSING INTERVENTION
RATIONALE
EVALUATION
SUBJECTIVE:

OBJECTIVE:
>Open wound due to surgical incision
>Bleeding episodes (amount, duration)
>Manifests body weakness
>Pale, cold, clammy skin
Risk for infection related to bleeding.
Wounds involving injury to soft tissue can vary from minor tears to severe crushing injuries. The decision to suture a wound depends
on the nature of the wound the time since the injury was sustained the degree of contamination.
Reference:
Brunner & Suddarths Textbook of Medical-Surgical Nursing 11th edition by Smeltzer, Bare, Hinkle, Cheever
After 1 hour of nursing interventions, the patient will be able to identify and verbalize interventions thatwill reduce the risk for
infection
>Assess signs and symptoms of infection especially temperature.
>Note the signs of fatigue, chills, anorexia, uterine contractions were flabby, and pelvic pain.
>Monitor uterine involution and lochia spending.

> Emphasize the importance of hand washing technique.


> Maintain aseptic technique when changing dressing/caring wound.
>Keep area around wound clean and dry.
> Emphasized necessity of taking antibiotics as ordered.
Collaboration:
Give antibiotics .
> Fever may indicate infection.
>The signs are an indication of the occurrence of bacteremia, shock is not detected.
>Uterine infection, inhibit involution and lochia spending prolonged occurs.
> It serves as a first line of defense against infection.
>Regular wound dressing promotes fast healing and drying of wounds.
>Wet area can be lodge area of bacteria
> Premature discontinuation of treatment when client begins to feel well may result in return of infection
>Antibiotics are necessary for the proper state of infection)
After 1 hour of nursing interventions, the patient was:

- Able to identify interventions that will reduce the risk for infection
-The client verbalized that he should take all his medication and clean the suture wound in the appendectomy site to reduce and
prevent infection

ASSESSMENT
NURSING DIAGNOSIS
RATIONALE
PLANNING
NURSING INTERVENTION
RATIONALE
EVALUATION
SUBJECTIVE:

OBJECTIVE:
PR: 122
>Restlessness
>Sweating
>Confusion.
>Shaking
>Irritability

Anxiety / Fear related to changes in circumstances or the threat of death.


A vague uneasy feeling of discomfort or dread accompanied by an automatic response; the source often non-specific or unknown to
the individual; a feeling of apprehension caused by anticipation of danger.It is an altering signal that warns of impending danger and
enables the individual to take measures to deal with threat.(NANDAp70)
After 3 hours of nursing interventions, the patient will be able to relax and anxiety will go away.
Independent:
>Establish rapport.
>Assess the client's psychological response to the post- childbirth bleeding.
>Assess the client's physiological responses (tachycardia, tachypnea, shaking).
>Treat the patient calm, empathetic and supportive attitude.
>Provide information about care and treatment.
>Help clients identify a sense of anxiety.
>Assess the client's coping mechanisms used.

>Establishing rapport can develop patients trust.

>Perceptions of client influence the intensity of anxiety.


>Changes in vital signs lead to changes in the physiological responses.
>Provide emotional support.
>Accurate information can reduce the anxiety and fear of the unknown.
>The expression can reduce feelings of anxiety.
>Prolonged Anxiety can be prevented with proper coping mechanisms.

After 3 hours of nursing intervention, goal was partially met, patient showed less signs of anxiety.