Nursing Care Plan Sa
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I.
NURSING CARE PLAN
Post-operative NCP CUES Subjective: – none Objective: Temp: 36.4˚C PR: 55 RR:22 CR:58 BP:110/70
DIAGNOSIS Ineffective airway clearance related to surgery anesthesia
RATIONALE
PLANNING STG: After 4 hours of nursing intervention, patient will be able to understand causative factors, identify signs of infection and report them to health care provider accordingly. LTG: After 2-3 days of nursing intervention, patient will achieve timely wound healing, be free of purulent drainage or erythema, be afebrile and be free of infection.
INTERVENTION
RATIONALE
Independent -Monitor vital signs
-To establish a baseline data
-Inspect dressing and perform wound care
-Moist from drainage can be a source of infection
- Monitor white blood count (WB
- Rising WBC indicates body’s efforts to combat pathogens; normal values: 4000 to 11,000 mm3
- Monitor Elevated temperature, Redness, swelling, increased pain, or purulent drainage at incisions - Wash hands and teach other caregivers to wash hands before contact with patient and
-these are signs of infection
-Friction and running water effectively remove microorganisms from hands. Washing between
EVALUATION Patient is expected to be free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.
between procedures with patient.
procedures reduces the risk of transmitting pathogens from one area of the body to another
- Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).
- Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).
- Encourage coughing and deep breathing; consider use of incentive spirometer.
- These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.
Independent: – Administe r antibiotics
PRIORITIZED PROBLEM
-Antibiotics have bactericidal effect that combats pathogens
1.Fluid volume deficit r/t post surgical fluid restriction
2.altered tissue perfusion r/t immobility during and after surgery
3.Fatigue r/t effect of surgery
4.pain r/t surgical incision
NURSING CARE PLAN
Post-operative NCP CUES Subjective: – none Objective: Temp: 36.4˚C PR: 55 RR:22 CR:58 BP:110/70
DIAGNOSIS Ineffective airway clearance related to surgery anesthesia
RATIONALE
PLANNING STG: After 4 hours of nursing intervention, patient will be able to understand causative factors, identify signs of infection and report them to health care provider accordingly. LTG: After 2-3 days of nursing intervention, patient will achieve timely wound healing, be free of purulent drainage or erythema, be afebrile and be free of infection.
INTERVENTION
RATIONALE
Independent -Monitor vital signs
-To establish a baseline data
-Inspect dressing and perform wound care
-Moist from drainage can be a source of infection
- Monitor white blood count (WB
- Rising WBC indicates body’s efforts to combat pathogens; normal values: 4000 to 11,000 mm3
- Monitor Elevated temperature, Redness, swelling, increased pain, or purulent drainage at incisions - Wash hands and teach other caregivers to wash hands before contact with patient and
-these are signs of infection
-Friction and running water effectively remove microorganisms from hands. Washing between
EVALUATION Patient is expected to be free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.
between procedures with patient.
procedures reduces the risk of transmitting pathogens from one area of the body to another
- Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).
- Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).
- Encourage coughing and deep breathing; consider use of incentive spirometer.
- These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.
Independent: – Administe r antibiotics
PRIORITIZED PROBLEM
-Antibiotics have bactericidal effect that combats pathogens
1.Fluid volume deficit r/t post surgical fluid restriction
2.altered tissue perfusion r/t immobility during and after surgery
3.Fatigue r/t effect of surgery
4.pain r/t surgical incision
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