Assessment
Subjective Data:
- Pain in the area of operation.
- Tired.
- Dizzy.
- Nausea, bloating.
- There is a wound in the groin.
- Fasting.
- Mucous membranes dry mouth.
Possible Nursing Diagnosis for Uterine Prolapse (Post Operative)
- Acute pain related to the surgical wound.
- Risk for fluid volume deficit related to vomiting after surgery.
- Impaired skin integrity related to the surgical wound.
- Risk for hypertermia related to surgical wound infection.
- Knowledge deficit: surgical wound care related to lack of information.
Nursing Interventions for Uterine Prolapse (Post Operative)
1. Acute pain related to the surgical wound.
Goal: Pain disappeared after the act of nursing.
Expected outcomes:
- Pain is reduced gradually.
- Assess the patient's pain intensity.
- Observation of vital signs and patient complaints.
- Place the patient on a bed with a technique that is appropriate to the surgery performed.
- Give the sleeping position that is fun and safe.
- Instruct the patient to immediately move gradually.
- Give appropriate analgesic therapy medical program.
- Take action with the child nursing care.
- Teach relaxation techniques.
2. Risk for fluid volume deficit related to vomiting after surgery.
Goal: There is no shortage of fluid volume.
Expected outcomes:
- Elastic skin turgor, not dry,
- No nausea and vomiting.
- Observation of vital signs every 4 hours.
- Monitor the infusion.
- Give drink and eat gradually.
- Monitor for signs of dehydration.
- Monitor and record the fluid in and out.
- Measure body weight per day.
- Record and inform the doctor about vomiting.
3. Impaired skin integrity related to the surgical wound.
Goal: Damage to skin integrity is resolved.
Expected outcomes:
- The surgical wound is clean, dry, no swelling. no bleeding.
Interventions:
- Observation of the state of the surgical wound of signs of inflammation: fever, redness, swelling and discharge.
- Treat the wound with sterile technique.
- Keep around the surgical wound.
- Give nutritious foods and encourage patients to eat.
- Involve the family to keep the clan surgical wound environment.
- Teach family in the care of the surgical wound.
4. Risk for hypertermia related to surgical wound infection.
Goal: Hyperthermia is resolved.
Expected outcomes:
- The surgical wound is clean, dry, not swollen. no bleeding.
- The temperature in the normal range (36-37 ° C).
- Observation of vital signs every 4 hours.
- Give appropriate antibiotic therapy medical program.
- Give a warm compress.
- Monitor the infusion.
- Ambulatory surgical wound with sterile technique.
- Keep the surgical wound.
- Monitor and record the fluid in and out.
5. Knowledge deficit: surgical wound care related to lack of information.
Goal: The client knows how to take care of the surgical wound.
Expected outcomes:
- Parents understand the operation wound care.
- Parents can maintain cleanliness and surgical wound treatment.
- Teach parents how to care for the surgical wound and keep it clean.
- Discuss about the wishes of the family wanted to know.
- Allow the patient's family to ask.
- Explain about the care of patients at home, do not wet and dirty bandage.
- Suggest to continue treatment / take medication regularly at home, and control back to the doctor.
Evaluation
- Obtain pain relief.
- Patients receive adequate fluid intake volume.
- Improved patient skin integrity.
- Good skin turgor.
- The client's body temperature within normal limits.
- Gain knowledge about uterine prolapse and treatment program.
- Mentions how the surgical wound care is good and right.
