Actual And Potential Ncp
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ACTUAL NURSING CARE PLAN ASSESSMENT S>”Medyo agnerbios ak nga maoperaan” O> vital signs taken as follows: -BP=140/80mmHg -RR=20cpm -PR=61bpm -T=36.5oC > non-conversant but cooperative > Able to do ADL as to bed mobility, feeding. >on NPO diet >not in respiratory distress
Nursing diagnosis: Mild anxiety related to upcoming surgical operation. (Prostatectomy)
EXPLANATION OF THE PROBLEM Renal function Test are advanced
indicating advanced BPH (Benign Prostatic Hyperplasia) urinary obstruction
urgency, frequency, hesitancy, decreased urine stream, and dribbling
surgical operation (prostatectomy) is indicated to prevent BPH
OBJECTIVES STO: Within 3 hours of nursing interventions, the patient will be able to identify ways to deal with and express anxiety.
LTO: Within 8 hours of nursing interventions, the patient will be able to appear relaxed and report anxiety is reduced to a manageable level.
NURSING INTERVENTIONS
RATIONALE
Dx: > Monitored vital signs and record accordingly.
> Serve as a baseline data
>Assessed respiratory status.
> To know if the patient is in respiratory distress.
Tx: >Established rapport.
> To gain trust and cooperation.
> Assisted patient on comfortable position. >acknowledged patient’s verbalization of anxiety. >IVF regulated and checked for patency. > Anticipated and attended to needs
> Helps to alleviate feeling of anxiety. > to assure that anxiety is a normal feeling. > to avoid circulatory overload. > For patient not to strain self.
Edx: > Encouraged on the following: mild anxiety to scheduled surgical operation
- to verbalize feelings and discomfort -
to take rest and sleep
- to have diversional activities like reading
> to know appropriate nursing interventions to be done. > provide comfort to the body causing relief of anxiety > for patient to address and reduced feelings of anxiety
EVALUATION STO: After 3 hours of nursing intervention, the patient was able to identify ways to deal with and express anxiety like conversing with SO’s and reading newspaper.
LTO: After 8 hours of nursing interventions, the patient was able to appear relaxed and report anxiety is reduced to a manageable level.
newspaper and conversing with SO”s > Emphasized the importance of therapeutic regimen. > Emphasized the presence of Significant others > Informed on NPO Diet.
> For patient to comply with the pharmacological interventions. > Help alleviate the anxiety of the patient >for patient to understand the reasons for NPO preoperatively
POTENTIAL NURSING CARE PLAN ASSESSMENT O>febrile, 38.5 >swelling surgical incision >redness noted on the surgical wound > wet surgical dressing > weakness in appearance >irritable >restless Nursing diagnosis: Risk for infection related to traumatized tissue secondary to post prostatectomy.
EXPLANATION OF THE PROBLEM Prostatectomy Surgical incision Tissue trauma
OBJECTIVES STO: Within 8hours of nursing interventions, the patient will be able to identify proper actions to prevent possible occurrence of infection and verbalize understandings of individual causative or risk factors of infection.
NURSING INTERVENTIONS Dx: > Monitor vital signs.
> observe for localized Signs of infection at insertion sites and at wound site > assess surgical incision
Opening of tissue
Possible Site of entry of pathogens causing infection
LTO: After 2 days of nursing interventions, the patient will achieve timely wound healing, be afebrile, and identify interventions to prevent or reduce infection.
Tx: >Establish rapport.
RATIONALE
> vital signs are important baseline data because it proves possible infection > to assess causative and contributing factors of infection > to note presence of infection and wound complications
> Assist patient on comfortable position. > maintain sterile technique in changing wound dressing
> To gain trust and cooperation. > for patient not to strain self. > to reduce or correct existing infection risk factors.
>perform TSB
> to address fever
> Acknowledge patients question regarding infection cause and control
> gives knowledge and background to patient regarding the cause and effects of infection
Risk for infection
>Give due antibiotics > Helps prevent infection. Edx: > Encourage on the following: - to increase fluid intake.
> Keep fluid and electrolyte balance of the body
EVALUATION STO: After 8hours of nursing intervention, the patient will be able to identify proper actions to prevent infection and verbalize understandings of individual causative risk factors of infection.
LTO: After 2 days of nursing interventions, patient will be able to achieve timely wound healing, be afebrile and identify interventions to prevent or reduce infection such as proper cleaning of wound aseptically.
- to take rest and sleep > helps the patient’s body to regain strength >emphasize necessity of taking antibiotics > for patient to cooperate in taking meds for infection control and prevention > instruct patient and significant others on proper prevention of infection
> to promote wellness and prevent infection
ACTUAL AND POTENTIAL NCP
Patient’s case: PROSTATECTOMY
Submitted to: Mr. Alimbuyao, Jeffrey Submitted by: Buangan, Jervise July 3, 2008
Nursing diagnosis: Mild anxiety related to upcoming surgical operation. (Prostatectomy)
EXPLANATION OF THE PROBLEM Renal function Test are advanced
indicating advanced BPH (Benign Prostatic Hyperplasia) urinary obstruction
urgency, frequency, hesitancy, decreased urine stream, and dribbling
surgical operation (prostatectomy) is indicated to prevent BPH
OBJECTIVES STO: Within 3 hours of nursing interventions, the patient will be able to identify ways to deal with and express anxiety.
LTO: Within 8 hours of nursing interventions, the patient will be able to appear relaxed and report anxiety is reduced to a manageable level.
NURSING INTERVENTIONS
RATIONALE
Dx: > Monitored vital signs and record accordingly.
> Serve as a baseline data
>Assessed respiratory status.
> To know if the patient is in respiratory distress.
Tx: >Established rapport.
> To gain trust and cooperation.
> Assisted patient on comfortable position. >acknowledged patient’s verbalization of anxiety. >IVF regulated and checked for patency. > Anticipated and attended to needs
> Helps to alleviate feeling of anxiety. > to assure that anxiety is a normal feeling. > to avoid circulatory overload. > For patient not to strain self.
Edx: > Encouraged on the following: mild anxiety to scheduled surgical operation
- to verbalize feelings and discomfort -
to take rest and sleep
- to have diversional activities like reading
> to know appropriate nursing interventions to be done. > provide comfort to the body causing relief of anxiety > for patient to address and reduced feelings of anxiety
EVALUATION STO: After 3 hours of nursing intervention, the patient was able to identify ways to deal with and express anxiety like conversing with SO’s and reading newspaper.
LTO: After 8 hours of nursing interventions, the patient was able to appear relaxed and report anxiety is reduced to a manageable level.
newspaper and conversing with SO”s > Emphasized the importance of therapeutic regimen. > Emphasized the presence of Significant others > Informed on NPO Diet.
> For patient to comply with the pharmacological interventions. > Help alleviate the anxiety of the patient >for patient to understand the reasons for NPO preoperatively
POTENTIAL NURSING CARE PLAN ASSESSMENT O>febrile, 38.5 >swelling surgical incision >redness noted on the surgical wound > wet surgical dressing > weakness in appearance >irritable >restless Nursing diagnosis: Risk for infection related to traumatized tissue secondary to post prostatectomy.
EXPLANATION OF THE PROBLEM Prostatectomy Surgical incision Tissue trauma
OBJECTIVES STO: Within 8hours of nursing interventions, the patient will be able to identify proper actions to prevent possible occurrence of infection and verbalize understandings of individual causative or risk factors of infection.
NURSING INTERVENTIONS Dx: > Monitor vital signs.
> observe for localized Signs of infection at insertion sites and at wound site > assess surgical incision
Opening of tissue
Possible Site of entry of pathogens causing infection
LTO: After 2 days of nursing interventions, the patient will achieve timely wound healing, be afebrile, and identify interventions to prevent or reduce infection.
Tx: >Establish rapport.
RATIONALE
> vital signs are important baseline data because it proves possible infection > to assess causative and contributing factors of infection > to note presence of infection and wound complications
> Assist patient on comfortable position. > maintain sterile technique in changing wound dressing
> To gain trust and cooperation. > for patient not to strain self. > to reduce or correct existing infection risk factors.
>perform TSB
> to address fever
> Acknowledge patients question regarding infection cause and control
> gives knowledge and background to patient regarding the cause and effects of infection
Risk for infection
>Give due antibiotics > Helps prevent infection. Edx: > Encourage on the following: - to increase fluid intake.
> Keep fluid and electrolyte balance of the body
EVALUATION STO: After 8hours of nursing intervention, the patient will be able to identify proper actions to prevent infection and verbalize understandings of individual causative risk factors of infection.
LTO: After 2 days of nursing interventions, patient will be able to achieve timely wound healing, be afebrile and identify interventions to prevent or reduce infection such as proper cleaning of wound aseptically.
- to take rest and sleep > helps the patient’s body to regain strength >emphasize necessity of taking antibiotics > for patient to cooperate in taking meds for infection control and prevention > instruct patient and significant others on proper prevention of infection
> to promote wellness and prevent infection
ACTUAL AND POTENTIAL NCP
Patient’s case: PROSTATECTOMY
Submitted to: Mr. Alimbuyao, Jeffrey Submitted by: Buangan, Jervise July 3, 2008
