example: damage to the skin / tissue (incision)
Characterized by:
- Objective Data : Conduct careful / distraction, anxiety, changes in vital signs
- Subjective Data : Report of pain
- reduced pain
- Saying controlled pain
- Shows the pain disappeared, was able to sleep / rest appropriately
- Assess pain, note the location, characteristics, intensity (scale 0-10)
- Encourage the patient to say the problem
- Provide comfort measures such as: change the position
- Encourage use of relaxation techniques
- Collaboration, give medication as indicated for example: analgesic
- Helps to evaluate: the degree of discomfort and the effectiveness of analgesics or may declare the occurrence of complications.
- Reduce anxiety / fear may increase the relaxation / comfort
- Prevent discomfort, increase relaxation and coping skills can be improved.
- Helping patients to rest more effective and refocus attention thus decreasing pain and discomfort
- Reduce pain, increase comfort.
2. Nursing Diagnosis : Impaired skin integrity related to surgical trauma
Characterized by:
- Objective Data: Damage to the skin, impaired healing
- Subjective Data: Report of the wound still not healed
- Normal skin, no visible damage
- Demonstrate appropriate wound healing without complications
Interventions:
- Protect the incision when changing position, coughing, deep breathing and ambulation
- Observe the incision is periodically
- Provide routine maintenance incision
- Reduce the possibility of an open wound sutures
- Affects choice of interventions
- Increases healing
Characterized by
- Objective Data: Changes in the amount of urine, the character of urine
- Subjective Data: Difficult in urination
Expected Outcomes : Demonstrate continuous flow of urine with urine output is adequate for individual situations.
Intervention:
- Record of urine output, probe reduction / cessation of flow suddenly urien
- Observe and record the color of urine
- Show catheterization techniques
- Encourage increased fluid intake and maintain accurate
- Monitor vital signs
- Decrease in urine flow may indicate a sudden obstruction / dysfunction
- The color of urine should be clear
- Periodic catheterization to empty the container
- Maintain good hydration and urine flow
- The indicator shows the level of hydration fluid balance and fluid replacement therapy effectiveness.
1. Assessment to change the perceived / actual
2. Complications can be prevented / minimal
3. Procedure / prognosis, therapeutic programs, potential complications understood and sources of support are identified.
Nursing Care Plan for Hypospadias with Assessment and Diagnosis
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