COLLEGE OF NURSING

Silliman University
Dumaguete City

KARDEX FOR IMMEDIATE POSTOPERATIVE PHASE

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