Vii
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ASSESSMENT
Objective: 2 days post cholecystectomy Presence of surgical incision at right upper quadrant Vital signs: Temp = 36° C
NURSING DIAGNOSIS
Risk for Infection related to surgical incision
PLAN OF CARE
EXPECTED OUTCOME
Independent:
Short Term:
Monitor vital signs every 4 hours.
After 30 minutes – 1 hour of nursing intervention, the patients’ risk for infection will be decreased.
Assess surgical site every four (4) hours or as indicated for any signs of infection (worsening pain, redness, swelling, warmth, loss of sensation). Observe strict hand washing while handling the patient. Observe aseptic technique during wound care and dressing change. Keep the dressing clean and dry. Encourage coughing and deep breathing exercises to avoid pressure on the wound. Position patient away from the operative site and avoid friction over the wound. Instruct patient to turn every 2 hours. Keep the linen wrinkled-free. Encourage early ambulation as allowed for faster wound healing and to improve the circulation. Provide health teachings: • About wound care and dressing change in preparation for discharge. Dependent: 27 Administer antibiotics as ordered by the physician.
EVALUATION Goals met: After 1 hour of nursing intervention, the patient’s risk for infection was decreased..
Long Term: The patient’s risk for infection will be minimized until surgical incision is healed.
s The patient’s risk for infection was minimized until surgical incision was healed.
28
Objective: 2 days post cholecystectomy Presence of surgical incision at right upper quadrant Vital signs: Temp = 36° C
NURSING DIAGNOSIS
Risk for Infection related to surgical incision
PLAN OF CARE
EXPECTED OUTCOME
Independent:
Short Term:
Monitor vital signs every 4 hours.
After 30 minutes – 1 hour of nursing intervention, the patients’ risk for infection will be decreased.
Assess surgical site every four (4) hours or as indicated for any signs of infection (worsening pain, redness, swelling, warmth, loss of sensation). Observe strict hand washing while handling the patient. Observe aseptic technique during wound care and dressing change. Keep the dressing clean and dry. Encourage coughing and deep breathing exercises to avoid pressure on the wound. Position patient away from the operative site and avoid friction over the wound. Instruct patient to turn every 2 hours. Keep the linen wrinkled-free. Encourage early ambulation as allowed for faster wound healing and to improve the circulation. Provide health teachings: • About wound care and dressing change in preparation for discharge. Dependent: 27 Administer antibiotics as ordered by the physician.
EVALUATION Goals met: After 1 hour of nursing intervention, the patient’s risk for infection was decreased..
Long Term: The patient’s risk for infection will be minimized until surgical incision is healed.
s The patient’s risk for infection was minimized until surgical incision was healed.
28
