COLLEGE OF NURSING
Silliman University
CUES/ EVIDENCES
Subjective:
Client verbalized,
 “Sakit e lihok tungod sa
tahi sa tiyan nako.”
 “Basin unya ma tang-
tang ning tahi sa ako
tiyan kung mag lihok
lihok ko.”
 Rated pain as 9 from
the pain rating scale of
0 to 10, where 10 as
the most painful and 0
as the minimal or no
pain felt
Objective:
 Vital signs
T = 35.8 C
PR = 80 bpm, strong,
regular
RR = 22 cpm shallow,
regular, with slight use of
accessory muscles
BP = 120/70 mmHg
Dumaguete City
KARDEX FOR IMMEDIATE POSTOPERATIVE PHASE
NURSING OBJECTIVES INTERVENTIONS
DIAGNOSIS
Impaired skin/tissue Within our 2 to 4 hours immediate
integrity related to postoperative nursing care, the client
mechanical will manifest intact skin integrity as
interruption of skin evidenced by:
(presence of surgical
wound) secondary to a. Absence of inflammation,
appendectomy redness, purulent discharges
on skin or operative site
b. Vital signs will remain in
normal range:
T = 36.5 - 37.5°C; afebrile
P = 60 – 100 bpm; regular and
strong
R = 12 – 20 cpm; regular, silent,
effortless, without use of
accessory muscles
BP = 110 – 140/60 – 90 mmHg
c. Demonstration of behaviours
to promote timely wound
healing or prevent skin
EVALUATION
Independent: After our 2 to 4 hours
immediate postoperative
1. Assess vital signs frequently. nursing care, the goals
were:
2. Inspect surrounding skin for
erythema, maceration, edema or a. Fully met
bleeding and note odors emmited
from the surgical incision. There was no presence
of inflammation,
3. Do proper aseptic wound care using redness or purulent
appropriate barrier dressings, wound discharges noted on
coverings or skin protective agents as the surgical site.
needed
4. Cleanse skin surface with diluted b. Partially met
hydrogen peroxide or running water
and mild soap after incision is sealed. T = 35.8 C
PR = 80 bpm, strong,
regular
5. Check tension of dressings. Apply
RR = 24 cpm shallow,
tape at center of incision to outer
regular, regular with
margin of dressing.
slight use of accessory
muscles
6. Give health teaching on proper
wound care or dressing and BP = 130/80 mmHg
importance of not touching the
wound. c. Fully met

 Surgical operation done:
Appendectomy
 Presence of surgical
wound on right lower
quadrant of abdomen
d. Report any altered sensation
 Spinal anesthesia with
Bupivacaine HCl 0.5% SAB
20 mg
 General anesthesia with
succinylcholine GETA 300
mg; 100 mg e. Absence of discomforts such
 Presence of redness on
the skin around the
surgical wound
 Minimal red discharges
on wound dressing f.
breakdown such as not
touching the wound or asking
the nurse to change the
dressing often and splinted
decision correctly
or pain at site of skin
impairment
as itching or pain on the
surgical site
Display timely healing of
surgical wound without
complications
7. Give health teaching on importance
of eating nutritious food such as
green leafy vegetables and fresh
fruits.
8. Give health teaching on the
importance of early ambulation.
Dependent:
1. Administer prescribed medications:
- metronidazole 500 mg IVTT q 8H
- ampicillin sulbactam 750 mg IVTT
q 8H
- nalbuphine HCl 10 mg IVTT
2. Refer to physician regarding the
change of dressing.
Demonstrated
behaviors to promote
timely wound healing
or preventing skin
breakdown by
refraining in touching
the wound.
d. Fully met
No altered sensation
reported.
Verbalized, “Mu sakit
nalang siya if kanang
mangusog ko pag ayo.”
e. Partially met
No itching on the
surgical site noted.
Rated pain as 4 from
the pain rating scale of
0 to 10.

g. Verbalized understanding of
eating nutritious foods to have f. Fully met
good skin integrity as an aid to
hasten wound healing Presence of minimal
red discharge on
wound dressing.

g. Fully met
Verbalized, “Pag sugtan
nako mu kaon, mga
gulay ako dapat kaunon
para dali ma ayo ako
samad.”