11. Nursing Care Plans

X.

NURSING CARE PLANS

ASSESSMENT SUBJECTIVE: “Masakit ang tahi ko” as verbalized by the patient. OBJECTIVE:  Restlessness  Irritability  With cold clammy skin  Excessive perspiration  Facial grimace  Increased respiration RR=26 bpm  Pain scale = 7: pain scaling of 110 where 1 is the least painful and 10 is the most painful  Impaired thought

DIAGNOSIS Pain related to tissue trauma and incisional discomfort as manifested by grimace and pain scale =7.

PLANNING After 4 hours of nursing intervention patient’s pain evidenced by pain scale =7 be reduced to 3.

NURSING INTERVENTIONS INTERVENTIONS RATIONALE  Change the position of the patient  Provide comfort measures  Assist patient in breathing techniques  Provide quiet environment  Relay on the patient report of pain  Encoura ge divertional activities  Monitor vital sign  Administer analgesic as ordered by the AP

 Pain is sometimes due to the position of the patient  To reduce the discomfort  To assist in muscle and generalized relaxation  For patient comfortabili-ty and lessen the discomfort.  To reduce anxiety felt by the patient  To divert the attention from pain to activities  Usually altered in pain.  To maintain acceptable level of pain.

EVALUATION After 4 hours of nursing intervention the patient reported pain was lessened to pain scale =3.

ASSESSMENT OBJECTIVE:  Poor skin turgor  Dry lips  Weak in appearance  Pale looking  v/s of: BP = 100/80 PR = 64 RR = 26  T = 37.8

DIAGNOSIS Fluid volume deficit related to the risk of post-operative hemorrhage as manifested by poor skin turgor, dry lips.

PLANNING After 8 hours of nursing intervention the patient will maintain fluid at a functional level.

NURSING INTERVENTIONS INTERVENTIONS RATIONALE  Change dressings frequently  Provide frequent oral care  Measure input and output

 To protect the skin and monitor losses  To prevent injury from dryness  Helps maintaining fluid in the body  To monitor fluids in the body

 Monitor v/s  Administer IV fluids as indicated  Give medications as ordered by the attending physician

 To assess the patient and it serve as base line data  To reduce blood loss

EVALUATION After 8 hours of nursing intervention, the patient was maintained fluid as manifested by good skin turgor

ASSESSMENT SUBJECTIVE: “Hindi ako makagalaw ng ayos” as verbalized by the patient. OBJECTIVE:  Impaired ability to turn side to side.  Cannot eat without support  Slowed movement  Irritable  Limited ROM

DIAGNOSIS Impaired mobility related to decreased muscle strength as manifested by limited ROM.

PLANNING After 8 hours of nursing intervention the patient will be able move safety and independently .

NURSING INTERVENTIONS INTERVENTIONS RATIONALE  Provide activities with adequate rest period.

 To reduce the fatigue

 Encouraged adequate intake of fluids

 Promotes well being and maximize energy production

 Advise to move hands and legs slowly

 To exercise/mobiliza tion of body parts and develop muscle strength

 Encourage participation in self care

 Enhances self concept and sense of independence

EVALUATION After 8 hours of nursing intervention, the patient was able to move safely and independently .