COLLEGE OF NURSING

NAME: Diana Anne V. Maris DATE: ________________________

CLINICAL INSTRUCTOR: Mrs. Lilian Ambito SCORE: _______________________

ASSESSMENT DIAGNOSIS ANALYSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Delayed Surgical Delayed Surgical Short Term: -Assess nutritional status -To determine if nutrition The patient is eating
“Bakit mas sumaakit siya Recovery related to Recovery is extension of Within 3 hours of nursing and current intake is adequate to support enough based on his
lalo habang tumatagal” as Postoperative Surgical the number of post intervention, the patient (Independent) healing nutritional needed for a
verbalized by the patient Site Infection operative days required to will have a pain score of (Nursing Pocket Guide, day. (Goal Met)
initiate and perform 5/10 or less. pg.928)
Pain scale: 10/10 activities that maintain
life, health, well-being.
Objective: -Perform daily wound -To clean the surgical The patient surgical
Long Term: care. (Independent) wound and to avoid wound was kept clean and
Patient showing Facial • After 7 days of infection. dry. (Goal Met)
Grimace Source: nursing intervention,
Nursing Pocket Guide, the patient wound is
Redness, Swelling, pg.926 free from infection.
drainage of cloudy pus • White blood cell and -Perform pain assessment -To ascertain whether During pain assessment
around the surgical site. temperature back to (Independent) pain management is the patient pain scale is
normal range. adequate to meet clients’ lessen with the score of
Patient surgical incision needs during recovery 5/10 (Goal Met)
site having wound (Nursing Pocket Guide,
dehiscence shows of pg.928)
bleeding.

T- 38.2 C -Assess circulation and -To evaluate for internal Patient surgical wound
WBC- 15.89 x109 /L sensation in surgical area bleeding that was cleansed and free
(Independent) compromises wound from bleeding (Goal Met)
integrity or loss of blood
flow to area, resulting in
decreased oxygen supply
to tissues, or nerve
damage, delaying healing
COLLEGE OF NURSING
- Assist the patient into a
position which reduces
intra-abdominal pressure
(Independent)
-Inspect incisions or
wounds routinely,
describing changes as
necessary (Independent)
-Administer /monitor
medication regimen
(Dependent)
(Nursing Pocket Guide,
pg.929)
-To prevent further strain Patient was doing Head-
on the wound and up positioning at
evisceration 30° (Goal Met)
(Nursing Pocket Guide,
pg.929)
-Observing the wound The patient surgical
bed early and often can wound showing of
help catch future possible changes that is free from
complications as early as redness, swelling, pus and
possible bleeding. The wbc shows
(Nursing Pocket Guide, 7.03 x109 /L and the
pg.929) temperature back to 36.2
C (Goal Met)
-To reduce the infection. -The patient's condition is
(Nursing Pocket Guide, getting better with no
pg.542) signs of infection (Goal
Met)
 COLLEGE OF NURSING