Ncp2

Patient’s Name: Terisita Tutor Address: Mabini Comval Province

NURSING CARE PLAN DATE

ASSESMENT

NEEDS

73 shift

Subjective: “Pasagdan lang man nku maghulat lng ko kung mahugaw najud unya ilisan na sa nurse.

P H Y S I O L O G I C

N O V E M B E R 13 2 0 0 8

Sex: Female Age: 43 yrs old

Objectives:  Fresh Surgical wound on the Right lower quadrant of the abdoment.  Untidy Wound dressing  Poor body hygiene  Swelling wound  Irritable face

N E E D S (Proper Hygiene)

NURSING DIAGNOSIS

PLAN OF CARE

Risk for Infection After 5 hours of related to Inadequate nursing care, Patient

primary defenses: remains free of broken skin, injured infection, as tissue. evidenced by: ® Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. Infections occur when an organism (e.g., bacterium, virus, fungus, or other parasite) invades a susceptible host. Breaks in the integument, the body’s first line of defense, and/or the mucous membranes allow invasion by

Absence of purulent drainage from wounds

NURSING INTERVENTION *Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient. ® Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e.g., perineal care or central line care). Use of disposable gloves does not reduce the need for hand washing. *Limit visitors. ® This reduces the number of organisms in patient’s environment and restricts visitation by individuals with any type

EVALUATION After 5 hours of nursing care, patient Experience free of infection as evidence by:  Having a clean, dry and intact wound dressing on the surgical site. 

Comfortable Feeling



having proper hygiene

pathogens. If the host’s (patient’s) immune system cannot combat the invading organism adequately, an infection occurs. Open wounds, traumatic or surgical, can be sites for infection; soft tissues (cells, fat, muscle) and organs (kidneys, lungs) can also be sites for infection either after trauma, invasive procedures, or by invasion of pathogens carried through the bloodstream or lymphatic system. Infections can be transmitted, either by contact or through airborne transmission, sexual contact, or sharing of intravenous (IV) drug paraphernalia.

of infection to reduce the transmission of pathogens to the patient at risk for infection. The most common modes of transmission are by direct contact (touching) and by droplet (airborne). * Teach

patient the importance of avoiding contact with those who have infections or colds. ® To prevent the spread of microorganism and to prevent infection.

*Change wound dressing if it is very bloody and Untidy.

®To prevent the risk of being infected by the microorganism. * encourage patient to take a bath everyday ® to have a good hygiene