Nursing Care Plan

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VIII: NURSING CARE PLAN

UNIVERSITY OF PANGASINAN PHINMA EDUCATION NETWORK
Arellano St., Dagupan City
College of Nursing

Name of Patient:________________________ Age:___ Sex:____ Medical Diagnosis:______________________
ASSESSMENT| NURSING DIAGNOSIS| NURSING ANALYSIS| GOAL &OUTCOMES| NURSING INTERVENTION| RATIONALES| EVALUATION| | Risk for infection related to postoperation| At increased risk for being invaded by pathogenic organisms| After 8 hours of nursing intervention, the patient will be able to demonstrate behaviours, lifestyle changes to reduce risk factors and protect self from injury.| * Stress proper handwashing techniques by all caregivers between therapies/clients. * Encourage early ambulation, deep breathing, coughing, and position change. * Maintain adequate hydration, stand/sit to void, and catheterize if necessary. * provide for isolation as indicates(eg., wound or skin reverse).| * A first-line defense against nosocamiak infection/cross-contamination. * For mobilization and respiratory secretions. * To avoid bladder distention. * Reduces risk of cross-cantamination.| After 8 hours of nursing intervention, the patient was now able to demonstrate behaviours, life-style changes that reduce risk factors and protect self from injury.|

UNIVERSITY OF PANGASINAN PHINMA EDUCATION NETWORK
Arellano St., Dagupan City
College of Nursing

Name of Patient:________________________ Age:___ Sex:____ Medical Diagnosis:______________________
ASSESSMENT| NURSING DIAGNOSIS| NURSING ANALYSIS| GOAL &OUTCOMES| NURSING INTERVENTION| RATIONALES| EVALUATION| S> “Masaki ang sugat ko” as verbalized by the patient.>with the pain scale of 6/10.O> guarded/protected behaviour.>facial grimace noted.>distractive behaviour/ seeking out other people and/ or activities).| Acute pain related to surgery AMB incision on hypogastric area.| Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.| After 8 hours of nursing intervention, the patient: * Verbalizes minimized or cantrolled feeling of pain. * Verbalizes methods that provide relief. * Demonstrates use of relaxation skills and diversional activities as indicated for his situation.| * Vital signs wre monitored q 15 minutes until stable and dressing was checked. * Assessed LOC and turned every 2 hours, to unoperative side only. * Instructed to do activities such as deep breathing exercise, coughing exercise, dorsiflexion of foot and sitting exercises. * Noted to avoid weight bearing until allowed. | * Alterations from normal may be signs of infection. Moistened dressings are favourable site or microorganism to culture. * One must beconscious and awake in order to feel pain. Turning of position prevent bed sores. * To reduce swelling and prevent stiffness, the stated activities must be done. Decreased lung capacity and decerased cogh efficiency are predisposing factors to respiratory infections. | Pain is reduced/controlled to a tolerable extent a verbalized. Relieving methods of relaxation techniques are understood and demonstrated.| UNIVERSITY OF PANGASINAN PHINMA EDUCATION NETWORK

Arellano St., Dagupan City
College of Nursing

Name of Patient:________________________ Age:___ Sex:____ Medical Diagnosis:______________________
ASSESSMENT| NURSING DIAGNOSIS| NURSING ANALYSIS| GOAL &OUTCOMES| NURSING INTERVENTION| RATIONALES| EVALUATION| S>“Masakit ang sugat ko kapag naglalakad ako” as verbalized by the patient. >With a pain scale of 6/10.O> gait changes (eg., decreased walking speed, small steps).>engages in substitutions for movement (eg., increased attention to other’s activity.>limited range of...
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